According
to
one
expert
at
Pitchbook,
two
core
issues
are
likely
to
dominate
healthcare
reform
discussions
in
2026:
rising
costs
and
flaws
in
Medicare
Advantage.
Healthcare
affordability
remains
a
major
systemic
issue
preventing
millions
of
Americans
from
accessing
care,
and
Medicare
Advantage’s
risk-adjustment
system
is
“clearly
broken,”
creating
incentives
that
pull
excess
money
into
the
program,
explained
Brian
Wright,
lead
analyst
for
healthcare
research
at
Pitchbook.
On
the
Affordable
Care
Act
and
commercial
market
side
of
things,
reforms
will
probably
aim
to
improve
affordability
and
risk
pooling,
he
said.
With
Medicaid
eligibility
pressures
pushing
providers
to
shift
costs
to
commercial
payers,
Wright
suggested
that
lawmakers
may
look
for
ways
to
make
the
commercial
market
function
more
effectively
rather
than
serve
as
the
system’s
subsidizer.
“Medicaid
eligibility
issues
are
going
to
pressure
hospital
systems
—
and
what
do
they
do?
They
typically
make
up
for
it
by
billing
to
the
commercial
side.
The
commercial
side
always
is
that
subsidizer
for
the
rest
of
the
healthcare
system.
So
the
thought
process
is
‘Okay,
how
can
you
go
about
making
a
market
on
the
commercial
side
work
better
than
it
is
now?’”
he
remarked.
One
potential
ACA-related
reform
involves
loosening
age
rating
restrictions,
Wright
noted.
Under
the
ACA
today,
payers
can
generally
charge
older
adults
no
more
than
three
times
what
they
charge
younger
adults.
If
those
limits
were
to
be
expanded
to
allow
payers
to
charge
older
adults,
say,
up
to
five
times
more,
then
there
would
be
lower
premiums
for
younger
people.
“That
way
younger,
healthier
people
are
incentivized
to
get
into
the
risk
pool,”
Wright
declared.
Another
potential
reform
would
give
states
greater
flexibility
to
define
minimum
coverage
standards
across
the
ACA’s
metal
tiers,
Wright
said.
This
would
allow
states
to
revisit
which
benefits
must
be
included
in
bronze,
silver
or
gold
plans,
rather
than
adhering
to
a
blanket
national
standard
—
which
might
give
payers
more
room
to
design
lower-cost
plans.
Wright
also
pointed
to
eliminating
or
reworking
so-called
“silver
loading
subsidies”,
a
pricing
practice
that
raises
premiums
for
silver
plans
to
offset
federal
cost-sharing
requirements.
He
said
the
approach
can
distort
pricing
across
the
market
and
influence
how
people
choose
their
plans.
In
addition,
other
reforms
could
include
expanding
wellness
incentives
and
giving
out
larger
financial
rewards
for
healthy
behaviors.
As
for
Medicare
Advantage
reform,
Wright
thinks
this
will
likely
center
on
addressing
flaws
in
risk
adjustment.
He
noted
that
while
Medicaid
also
uses
risk
adjustment,
it
does
not
incentivize
plans
to
increase
coding
in
ways
that
drive
higher
overall
spending.
Moving
Medicare
Advantage
toward
using
full
claims
and
encounter
data
—
rather
than
partial
data
—
could
help
limit
those
incentives
and
rein
in
costs.
While
none
of
these
potential
changes
are
guaranteed
to
materialize
in
2026,
Wright
said
they
reflect
a
growing
willingness
among
policymakers
to
rethink
the
long-standing
rules
that
have
shaped
healthcare
costs
and
coverage.
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