Insights

HMA Insights: Your source for healthcare news, ideas and analysis.

HMA Insights – including our new podcast – puts the vast depth of HMA’s 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.

Show All | Podcast | Blogs | Webinars | Weekly Roundup | Videos | Case Studies | Reports | News | Spotlight

Filter by topic:

Receive timely expert insights on topics you care about.

Select Topics

331 Results found.

Blog

Spotlight on Development of President Trump’s Children’s Health Strategy

Read Blog

This week, our In Focus section highlights President Trump’s Make America Healthy Again (MAHA) executive order, which is designed to address the challenges driving chronic diseases in the United States. Our article delves into the key components of the order, presents a data snapshot about the state of children’s health, and discusses implications for stakeholders seeking to prepare for and inform the transitions impacting the future of children’s health. 

Presidents can use executive orders to communicate their priorities and set a framework and timelines for federal agency actions. Historically, these orders have provided strong signals for the initiatives and policy direction that federal departments and agencies will pursue. Health Management Associates (HMA), experts are monitoring the MAHA directive and several other executive orders, alongside other Trump Administration actions. 

Executive Order: Making Children Healthy 

On February 13, 2025, President Trump signed an executive order establishing the Make America Healthy Again Commission, chaired by US Department of Health & Human Services (HHS) Secretary Robert F. Kennedy, Jr. The commission, which builds on the Secretary’s prior work, is charged with combating “critical health challenges facing citizens, including the rising rates of mental health disorders, obesity, diabetes, and other chronic diseases.” 

Initially, the commission will focus on studying and addressing childhood chronic diseases. The order directs the commission to release within 30 days an assessment that summarizes what is known about the childhood chronic disease crisis, identifies gaps in knowledge, and includes international comparisons. This report will serve as the foundation for developing a strategy to improve the health of children, which is due within 180 days of the order. 

Data Snapshot: Childhood Chronic Conditions 

Evaluating existing data and identifying gaps in data for children are critical initial steps toward developing a comprehensive and evidence-driven federal policy agenda. At present, 90 percent of the $4.5 trillion in annual US healthcare expenditures are used to provide services to people with chronic and mental health conditions. Many of the risk factors for developing these conditions begin in childhood and some are preventable. For example: 

  • Obesity affects 20 percent of children and 42 percent of adults, putting them at risk of chronic diseases such as type 2 diabetes, heart disease, and some cancers. More than one in three young adults ages 17−24 are too heavy to join the US military. The youth obesity rate from 2017−2020 was 19.7 percent, a 42 percent increase from the rate in 1999−2000. Lifestyle choices, combined with social and environmental factors like access to healthy foods and neighborhood walkability and safety can significantly reduce the risk of developing obesity. 
  • In 2022, diabetes and the complications associated with it accounted for $413 billion in total medical costs and lost wages in the United States. While few children have type 2 diabetes, nearly one in five adolescents (12−18 years old) have prediabetes and may develop diabetes in adulthood. Like obesity, both personal choices and adverse social and environmental factors can increase the lifetime risk of developing diabetes. 
  • Approximately 4.9 million children in the United States have asthma, which is incurable but can be managed. Asthma is one of the main causes for missed school days among children. Many US schools have poor indoor air quality, which can expose children to allergens, irritants, and triggers such as mold, dust, and pests. Conditions in children’s homes also can exacerbate asthma.

How Federal Programs Impact Children’s Health 

Numerous federal programs directly and indirectly affect children’s health. Examples include: 

  • Nationally, more than 38 percent of children have Medicaid coverage, with rates exceeding 50 percent in some states and territories (e.g., Louisiana, New Mexico, Puerto Rico). Medicaid’s requirement to cover Early Periodic Screening, Diagnostic and Treatment (EPSDT) has long been the vehicle for addressing the chronic healthcare needs of children on Medicaid. For example, for children with asthma, in addition to covering medications to prevent and treat exacerbations, some states will reimburse providers for conducting home health assessments to identify and remediate triggers in the home. In addition, federal funding through both Medicaid and US Department of Education supports school nurses and school-based health centers, which can be critical resources in addressing the chronic healthcare needs of students, such as the administration of Insulin or providing inhalers to children experiencing asthma. 
  • To receive funding through the National School Lunch and School Breakfast programs, schools must provide meals aligned with the “meal pattern” established by US Department of Agriculture, which specifies the amount of food among various groups and an age-based maximum for calories, saturated fat, and sodium. Under current guidelines, by 2027, school meals also will be expected to comply with limits on added sugars. 
  • Participants in the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC), which provides participants with certain foods to meet their nutritional needs, have a lower risk for preterm birth, low birthweight infants, and infant mortality. 

Federal programs affect children’s home and school environment in other ways, and the health implications of those funding choices may not be explicitly recognized or prioritized. For example: 

  • Housing assistance programs in some cases prevent families from experiencing homelessness but may place them in living situations where exposure to environmental hazards such as mold, pests, or pollution and neighborhood factors like crime and lack of walkability may adversely affect their health. 
  • Some federal agriculture programs are specifically designed to make nutritious foods available (e.g., Gus Schumacher Nutrition Incentive Program, or GusNIP), while others support agriculture without specifically bringing a health lens to those programs.

Implications for Stakeholders 

The President has directed that the strategy address “appropriately restructuring the Federal Government’s response to the childhood chronic disease crisis, including by ending Federal practices that exacerbate the health crisis or unsuccessfully attempt to address it, and by adding powerful new solutions that will end childhood chronic disease.” Though we do not know what the Make our Children Healthy Again Assessment and Strategy will recommend, we anticipate it will present both opportunities and risks for organizations focused on children’s health. As the commission begins its work, organizations can take the following actions: 

  • Consider policy opportunities: Review your organization’s strategic plan as well as your operational and policy priorities and consider how they may fit into this framework. This could be the time to suggest changes to federal grants you receive or federal regulations or requirements that negatively affect your ability to keep children healthy. 
  • Prepare for potential funding disruptions: It is possible that programs you rely on will have changes in scope or funding levels. Review your offerings for children with chronic conditions and identify substitutes or complements to your main priorities. Consider partners you might work with to keep work going that may not have the same level of federal support in the future. 
  • Be prepared to share the real-world impacts of policy changes: Begin gathering data, stories, and compelling information to share about chronic conditions affecting children that can be used in future public comment opportunities, shared with the media, and discussed with your federal, state, and local representatives. Think about how to talk about these issues in a clear and compelling way that will resonate with each of those audiences. 
  • Find partners and allies: As you consider the policy opportunities and risks, think about other organizations that share your interests and how you can work with them in complementary ways. It can be compelling to policymakers when stakeholders who might not naturally be aligned on other issues can unite around a specific policy area. 

Connect with Us 

Healthcare stakeholders with a commitment to healthy children and healthy adults have an opportunity to support the specific policies and funding opportunities that may emerge from the MAHA order. To learn more about these policy changes, the impact on your organization, and actions your organization can take, contact our one of our featured experts below. 

Brief & Report

State Cost Growth Benchmarking Programs: An Evaluation of Eight States’ Experiences and the Lessons Stakeholders Have Learned

Download

Background

In 2024, Health Management Associates (HMA) evaluated programs implemented by eight states (California, Connecticut, Delaware, Massachusetts, New Jersey, Oregon, Rhode Island, and Washington) aimed at controlling healthcare cost growth. In recent years, these states have tried to address the trend of escalating healthcare costs using an approach referred to as cost growth benchmarking (CGB). This is the act of setting a target for annual healthcare cost growth and measuring actual performance against the target. Since 2018, the Peterson-Milbank Program (PMP) for Sustainable Health Care Costs has invested in state-based CGB efforts by funding program development, implementation, and technical assistance. HMA evaluated the Peterson Center on Healthcare’s cost growth benchmarking efforts across the eight states.

Methodology

HMA’s evaluation for the Peterson Center on Healthcare included a detailed landscape review for each of the eight states and interviews with 45 state officials, providers, payers, and other stakeholders in these states. The HMA team synthesized findings from the landscape review and the key informant interviews and produced an internal evaluation report.

Analytic Approach

The landscape review captured the state’s CGB program chronology, governance structure, growth targets, enforcement authority, and performance against the target. The interviews examined the contextual factors, stakeholder influence, implementation developments, capacity to control costs, facilitators and barriers to developing cost control capabilities, and the lessons learned based on the states’ experience. The interview discussion guide included a scoring component which enabled quantitative analysis in addition to the qualitative findings. HMA analyzed these findings by state, category of interviewee (state officials, payers, providers, or others) and implementation stage (early vs. more recent adopters).

Findings

States’ efforts to engage and gather stakeholders, establish cost growth targets, collect and report data, and identify cost drivers have been successful, but states have had challenges to date in developing policies aimed at containing costs.

Utility

The findings from this analysis can be useful to the existing states in enhancing their CGB programs and to states interested in launching new CGB initiatives.

Brief & Report

Medicare Hospital Inpatient Device-Intensive Payment Policy

Download

Medicare’s fee-for-service (FFS) payment system includes payment policies that support providers’ use of innovative medical device technologies. The continued evolution of these policies is necessary to keep pace with current and future medical innovation. In this report, HMA summarizes models testing the implementation of a newly proposed policy for the hospital inpatient system which aims to eliminate systemic bias that may slow hospitals’ adoption of innovative technologies. HMA concludes that targeted policies that eliminate the use of the hospital wage index to standardize device costs can result in more accurate reimbursement for hospitals and increase beneficiary access to innovative technologies.

Blog

Highlights from HMA Analysis of Specialty Services in Medicaid

Read Blog

This week, our In Focus section highlights key insights from a new Health Management Associates (HMA), white paper, Concentration of Specialty Services in Medicaid. Experts from HMA and Wakely, an HMA company, used the national Transformed Medicaid Statistical Information System (T-MSIS) database to learn more about specialty provider networks and examine the provision of specialty services across various states.  

The analysis, released in January 2025 with support from the Robert Wood Johnson Foundation, focuses on three representative services that are relatively common, potentially difficult for Medicaid beneficiaries to access, significantly affect quality of life, typically accessed as elective procedures, and unlikely to be provided by other clinicians, such as primary care or mid-level practitioners.  

T-MSIS Analysis Overview  

T-MSIS analytic files are a comprehensive resource for Medicaid encounter, beneficiary demographics, program enrollment, service utilization, and payment data. Individual states compile their Medicaid claims data and submit monthly files to the Centers for Medicare & Medicaid Services (CMS). As each state submits data individually, numerous state-specific variations occur in data availability and quality. Currently, T-MSIS data are available for 2016−2023. HMA data scientists have permission to use the T-MSIS files for healthcare services research. 

This paper examines services in 10 states that met a threshold of data integrity in the T-MSIS dataset for 2022. Other important design aspects of the analysis are as follows:  

  • The three service procedures included in the analysis are total knee replacement (TKA), cataract removal, and impacted tooth extraction. 
  • Selected states represented a diverse sample of geographic, socioeconomic, and other demographic factors.  
  • The analysis includes non-dually eligible adult populations, ages 22−64 years.  
  • The data cover all services provided in 2022 for each procedure and the providers who rendered the service; facilities are excluded.  

Concentration of Specialty Providers  

Table 1 summarizes findings about the concentration of specialty services.  

table of percentage of procedures rendered by top ten percent of providers

The authors further analyzed the provision of services and, building on a previous study, examined network concentration. Findings were as follows: 

  • When looking at the same procedure across states, no consistent pattern emerged regarding which states had the highest and lowest concentration of services in the top 10/25 percentile of providers. 
  • However, when looking at the same procedure across multiple states, TKA tended to have the lowest concentration of services among those studied.  
  • Regardless of procedure and state, the 50 percent of providers with the lowest number of procedures tended to provide fewer than 10 percent of the total services combined. 

These findings suggest that the specialty networks within each state are highly nuanced, and state policymakers need to look at individual specialty networks when considering health policy. State policymakers and managed care organizations (MCOs) need to examine each specialty individually to assess the distribution of services and access to care. 

Looking Ahead  

Timely access to healthcare services is critical for ensuring optimal health outcomes. The report authors’ analysis of T-MSIS data showed significant concentration of selected specialty services among providers, which may affect appropriate access to these services.  

The analysis of concentration of specialty services among Medicaid specialty providers can guide MCOs and state policymakers in developing strategies to improve network adequacy, including clarifying the level of network adequacy and developing policies to assess and regulate access to specialty care. Addressing gaps in access to specialty care can contribute to better health outcomes for Medicaid beneficiaries and may be aligned with provisions in value-based contracts.  

Connect with Us 

Medicaid consumers, providers, MCOs, and states all have an interest in ensuring access to specialty care for Medicaid beneficiaries. The methodology applied in the analysis for the HMA white paper can be applied and adapted for future analysis to monitor network stability and to compare access among various payers.  

For details about this analysis, its implications for state and local policies, and additional research using T-MSIS, contact our experts below.

Webinar

Webinar Replay: Medicaid in Motion – Navigating Post-Election Policy Changes and Opportunities

Watch Now

This webinar was held February 26, 2025.

During this webinar, our experts as discussed the latest developments in Medicaid financing and policy. With Congressional leaders and new U.S. Department of Health and Human Services officials focusing on Medicaid, significant changes are on the table during the budget reconciliation process. These changes create both risks and opportunities for Medicaid stakeholders. Learn what Congress and the Administration are considering and how it impacts Medicaid markets.

Learning Objectives:

  • Understand recent and potential federal statutory and regulatory policy changes affecting Medicaid.
  • Identify potential impacts of these policy changes on Medicaid programs, payers, healthcare providers, industry, and beneficiaries.
  • Explore changes in Medicaid funding structures and reimbursement mechanisms resulting from federal policy updates.
  • Discover feasible practices and strategies to adapt to the evolving federal policy landscape.
Blog

Could Congress Compromise Ohio’s Budget through Medicaid?

Read Blog

As policymakers engage the state budget process, Medicaid continues to play a critical role. This role is programmatic, serving as the source of coverage for 1 in 4 Ohioans, including as the finance mechanism for half of all births in the state and the primary source of coverage for the elderly and disabled. However, a number of proposals are currently being discussed by the House, including changing how poverty programs are adjusted for inflation, reversing some Medicaid payment expansions, lowering the minimum federal funding rate for Medicaid, making the federal funding rate the same for all Medicaid expansion populations, limiting taxes on Medicaid providers, capping the amount spent per Medicaid enrollee, standardizing how administrative costs are matched, and other unspecified changes to Medicaid funding through Medicaid match. But these proposals can’t be viewed in isolation because the program is deeply intertwined with Ohio’s ability to have a balanced budget, serving a role in reducing direct state spending by enabling the draw down of federal dollars through “FMAP.” But what is FMAP and what happens if Congress fundamentally changes how it’s calculated?

FMAP

The Federal Medical Assistance Percentage (FMAP) is a critical component of Medicaid funding, ensuring that states receive federal support to provide healthcare services to low-income individuals. FMAP is calculated based on a state’s per capita income relative to the national average. States with lower per capita incomes receive a higher FMAP, meaning the federal government covers a larger share of Medicaid costs, while states with higher per capita incomes receive a lower FMAP. The FMAP formula ensures that states with greater financial need, like Ohio, receive more federal assistance. For Federal Fiscal Year (FFY) 2025, Ohio’s FMAP is 64.6%, which means that for every dollar Ohio spends on most Medicaid services, 64.6 cents comes from the federal government. Even then, much of the state share is financed through fees on entities like hospitals, nursing facilities and health insurance companies.  

Contextually, Ohio is a “recipient state,” indicating it receives more in federal tax revenue than it collects to finance the program. And, as was noted in the initial testimony offered in the Ohio House, Ohio continues to lag other states in terms of economic growth and has an aging population. As such, the availability and predictability of federal funding is a critical input in future years, particularly in long term care where most of the expense will continue to increase. With Congress deliberating all of these proposals, what could the impact be in Ohio? To illustrate, it may be good to focus on one area: the elimination of enhanced federal funding for those covered by the Medicaid expansion.

Impacts

There has been some discussion during testimony that if the FMAP rate for the expansion population were to change, it could trigger an automatic end to the expansion itself.  Importantly, there would be a disproportionate impact in Ohio’s rural counties where expansion coverage rates are higher. In fact, as of December 2024, 362,829 individuals in rural Ohio counties received their coverage through expansion, alone. These individuals, in addition to the 1.1 million others in these Ohio counties, rely on Medicaid for essential healthcare services, including addiction treatment.

In states with expansion, coverage for individuals with SUD has doubled highlighting the importance of maintaining robust funding for these programs. Expansion has also been the primary source of funding for addiction treatment in the state, with Medicaid covering half of all buprenorphine treatments. If expansion were eliminated due to the change in FMAP, the consequences for treatment may mean either a greater obligation on the state to finance those services directly, or, Ohio may exacerbate the opioid use disorder crisis, putting additional strain on our healthcare system, particularly for behavioral health providers.

Conclusion

As we consider the future of Ohio’s Medicaid expansion, it’s essential to recognize the critical role that FMAP plays in sustaining our healthcare system and supporting our state’s economy. Any changes to the FMAP rate must be carefully evaluated to ensure that we do not undermine the progress we have made in expanding access to care and addressing the opioid crisis.

Beyond the immediate impact on healthcare services, changes to FMAP could also have broader economic implications for Ohio. Medicaid represents about 4% of the state’s GDP, playing a vital role in supporting jobs and economic activity. If just 1% of that GDP were suddenly eliminated due to a cut in federal or state funding, the consequences could be severe. A sudden reduction in Medicaid funding could lead to job losses in the healthcare sector, reduced economic activity, reduced labor force participation, and increased financial strain on state and local governments. The ripple effects would be felt across the economy, impacting not only healthcare providers but also businesses and communities that rely on the stability and support provided by Medicaid as well as the budgetary stability it provides to Ohio’s process.

Brief & Report

340B Duplicate Discounts: Enforcement Inconsistent and Weak Due to Lack of Data Transparency and Despite Federal Prohibition

Download

At the intersection of the federal 340B Drug Pricing program and the federal Medicaid Drug Rebate Program (MDRP), a potentially large set of Medicaid claims are generating duplicate discounts, which pharmaceutical manufacturers provide to eligible entities such as hospitals and health centers. These two complex federal programs were designed to reduce the costs of prescription drugs for providers that serve low-income patients, but both state Medicaid agencies and federal policymakers have been actively working to eliminate the unintended overlap of these two programs. To gain deeper insights into why duplicate discounts continue to occur, the scope of this concern, and to identify considerations of future policymaking, HMA conducted interviews with Medicaid officials and drug policy experts across several states.

Duplicate discounts occur when for a single sale a manufacturer is required to: (1) prospectively reduce the price of the product (a discount) they sell to a 340B covered entity in advance of the delivery of care to the patient; and (2) provide a retrospective payment (a rebate) to a state Medicaid program or managed care plan under the MDRP after care is delivered to a Medicaid enrollee. When duplicate discounts occur the manufacturer’s product is discounted twice for the same sale, contravening federal law, which prohibits duplicate discounts.

Despite the statutory prohibition, duplicate discounts remain a concern. Both state and federal policymakers have been actively addressing duplicate discounts but have been unable to identify clear and consistent policy solutions that neutralize this inefficiency. On the state level, Medicaid agencies and state legislatures have implemented policies to address duplicate discounts. On the federal level, the Health Resources and Services Administration (HRSA) and the Centers for Medicare & Medicaid Services (CMS) have conducted audits and published best practices for states to eliminate duplicate discounts. Nonetheless, duplicate discounts persist. 

To gain deeper insights into how Medicaid agencies navigate duplicate discounts, Health Management Associates (HMA) conducted semi-structured interviews with former and current Medicaid directors and pharmaceutical policy experts in 14 states. Interviewees were asked about the frequency of duplicate discounts, the extent to which Medicaid agencies devote resources to tracking them, the policies states have implemented to address them, and the extent to which state or federal authorities are working to eliminate duplicate discounts.

Based on interviews, four key themes emerged:

  • Duplicate discounts remain a problem, the scope of the problem is unclear, and better data collection from covered entities is necessary.
  • The opacity and complexity of duplicate discounts create a burden for state Medicaid agencies, influencing the policies they implement, resulting in variable state policy strategies.
  • Contract pharmacies add an additional layer of complexity, exacerbating the burden that duplicate discounts create.
  • State and federal authorities could take more decisive action to address duplicate discounts.

Policymakers should consider that the environment for addressing duplicate discounts may become more complex in the future, which may increase the need for a federally coordinated policy solution. The complexity of the environment may deepen due to the increasing presence of contract pharmacies, the increasing presence of managed care in Medicaid programs, and the implementation of the drug pricing policies of the Inflation Reduction Act of 2022. Policy action coordinated across the various stakeholders (e.g., HRSA, CMS, state Medicaid agencies, covered entities, and manufacturers) may represent the best opportunity for success in eliminating duplicate discounts.

Blog

A Closer Look at Gubernatorial Healthcare Priorities: 2025 State of the State Address Overview

Read Blog

This week, our In Focus section examines governors’ healthcare priorities from their 2025 State of the State addresses. This article highlights common themes in addresses delivered between January 6, 2025, and January 16, 2025, and delves into specific proposals in Georgia, Iowa, New York, and Oregon, as analyzed in the Health Management Associates (HMA), Information Services (HMAIS) interim report, 2025 State of the State Overview.

State of the States in the Current Environment

Governors use their State of the State addresses to outline their priorities for the year, giving insight into the agendas and initiatives that their executive branches may pursue independently or in collaboration with their state legislature. These priorities often are informed by the status of the state’s budget, with some governors advancing healthcare proposals that will address budget deficits and others seeking to invest in services and workforce initiatives.

Monitoring governors’ policy priorities and initiatives is especially important in 2025 given the changing federal landscape. The transition in both the administration and Congress will require state leaders to carefully consider the risks and opportunities. As detailed below, governors’ responses will unfold differently across states and markets.

Common Threads

In all, 24 governors delivered a State of the State Address between January 6, 2025, and January 16, 2025. Many gubernatorial leaders have similar areas of priority and concern, with some continuing multiyear initiatives to address unmet behavioral health needs and control healthcare costs. Table 1 identifies the themes emerging from the first group of addresses.

Governors also are considering possible policy changes under the new Trump Administration. For example, some governors reported that their state is looking to strengthen or add Medicaid work requirements to their programs, resuming initiatives that were initially pursued during the first Trump Administration. Though not directly related to healthcare, governors’ decisions to mirror President Trump’s Department of Government Efficiency, with Iowa as an example, could indirectly affect local programs and markets. Other states are considering the implications of possible changes to federal Medicaid funding. A deeper look into the priorities in Georgia, Iowa, New York, and Oregon follows.

Georgia

Gov. Brian Kemp delivered Georgia’s State of the State address on January 16, 2025, during which he focused his healthcare remarks on the state’s Pathways to Coverage Section 1115 demonstration. Georgia’s waiver extends Medicaid coverage to able-bodied adults who earn up to the federal poverty level if they meet certain work requirements. The governor emphasized that he intends to work with the Trump Administration to further advance innovative approaches to healthcare access.

Governor Kemp stated that his administration is making it easier to apply for Medicaid coverage and will submit an amendment to the Centers for Medicare & Medicaid Services (CMS) that would extend the Pathways demonstration for five years beyond the current expiration date of September 30, 2025. The state plans to request several changes to the demonstration, including:

  • Changing the reporting requirements for qualified work activities
  • Adding more activities that qualify for program eligibility
  • Adding a retroactive coverage policy
  • Removing premiums and Member Reports Accounts

The governor’s proposed fiscal year (FY) 2026 budget includes $324 million to fully fund projected Medicaid enrollment and utilization growth and $36 million in additional support for pharmacy benefits, including recently approved gene therapy treatments for sickle cell disease.

Iowa

Iowa Gov. Kim Reynolds delivered the Condition of the State Address on January 14, 2025, during which she called for increased Medicaid reimbursement rates for OB/GYNs and primary care physicians who provide care to people with complex pregnancy cases, as well as certified nurse midwives. The governor also said she was in favor of adding doula services as a covered Medicaid benefit. Governor Reynolds is one of several governors who have announced plans to pursue a Section 1115 demonstration for Medicaid work requirements for able-bodied adults.

Governor Reynolds’s proposed FY 2026 budget includes investing $642,000 in newly unbundled Medicaid maternal rates, and more than double investments in five existing state healthcare loan repayment programs. The governor also proposes to establish a Medicaid Graduate Medical Education enhanced payment to draw down more than $150 million in federal dollars for more residency spots in Iowa’s teaching hospitals.

New York

New York Gov. Kathy Hochul delivered her State of the State Address on January 14, 2025, at which time she also released a State of the State Book. Addressing behavioral health is one of her chief priorities, and proposals include:

  • Allowing more involuntary commitments for people with severe mental illness
  • Developing programs to support youth mental health through after school programs
  • Expanding peer support programs
  • Improving the diagnostic process for children with complex needs
  • Supporting mental wellness in historically marginalized neighborhoods
  • Expanding Mobile Medication Units to bring opioid treatments to underserved areas

Governor Hochul intends to expand support for the state’s healthcare safety net. This part of her agenda would provide financial assistance to struggling medical facilities and hospitals through expansion of the state’s Safety Net Transformation Program and participation in the US Food and Drug Administration’s program that allows states to import lower-cost drugs from Canada.

The governor’s proposed $252 billion budget for FY 2026 would allocate $35.4 billion for the state Health Department’s Medicaid budget—a 14 percent increase from last year. Governor Hochul plans to offset some of the spending hike with revenue from the newly approved managed care organization tax, which is expected to raise $3.7 billion to help balance the state budget over three years.

Oregon

Gov. Tina Kotek delivered Oregon’s 2025 State of the State Address on January 13, 2025. The governor has a significant focus on mental health and substance use disorder treatment, as well as housing as an HRSN. Governor Kotek wants to strengthen the behavioral health system and proposed adding new treatment beds, increasing treatment capacity, eliminating backlogs at the state’s health licensing boards to improve access to qualified counselors, improving the provider pipeline, and increasing worker retention. During her speech, the governor also called for improved frontend care coordination to decrease the overflow of people at the Oregon State Hospital.

In addition, the governor intends to work toward improving care for the civil commitment population (i.e., people who are involuntarily detained in a psychiatric hospital) by dedicating permanent supportive housing funds to expanded residences with onsite services. Governor Kotek has directed her team to develop a new intensive permanent supportive housing model to more effectively support people with serious mental health needs.

Governor Kotek’s proposed budget for the 2025−2027 biennium includes $39.6 billion for the Oregon Health Authority, representing a 10.4 percent increase from the approved budget for 2023−2025. This budget includes $29.6 billion for the state Medicaid program and $1.6 billion for the Behavioral Health Division, in addition to $732.4 million for the division from the General Fund.

Connect With Us

HMAIS has prepared a comprehensive report summarizing each State of the State Address, which is available to HMAIS subscribers. The report also examines proposed budgets, highlighting key financial commitments and allocations that underscore these priorities for the upcoming year. The first iteration of the report covers AR, AZ, CO, CT, GA, IA, ID, KS, KY, MA, MT, ND, NE, NH, NJ, NV, NY, OR, RI, SD, VA, VT, WA, and WY. The document will be updated periodically as speeches occur.

Contact our experts below for more information about the report or to connect with one of HMA’s state policy and market experts.

Blog

Executive Actions and Congressional Budget Reconciliation: Trump Administration’s 2025 Healthcare Overhaul

Read Blog

This week, our In Focus section highlights how the new Administration and Congress are poised to significantly change healthcare policies, ranging from health equity and Affordable Care Act (ACA) Marketplace subsidies to Medicaid services and prescription drug costs. Stakeholders seeking to influence these potential changes should plan to engage quickly. Today’s section covers important developments that occurred through 2 pm January 29, and healthcare stakeholders will need to remain attune to future developments impacting federal healthcare programs.  

Executive Action 

Over the first week of his second term, President Donald J. Trump has issued several executive orders (EOs) and presidential directives affecting healthcare stakeholders. Presidents have increasingly used EOs at the beginning of their administration to rescind policies of their predecessors and direct the federal departments and agencies to exercise their authorities in line with the president’s directives. 

Though some EOs require no further action, many are just the beginning of the policymaking process, with agencies tasked with implementing the directives. This timeline can provide stakeholders with opportunities to work with to policymakers to inform how they shape the rules for compliance with these directives. 

Initial EOs issued so far by President Trump include policies that: 

  • Rescind several of former President Biden’s Executive Orders, including:
    • Executive Order 13985 of January 20, 2021, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government 
    • Executive Order 13988 of January 20, 2021, Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation 
    • Executive Order 13990 of January 20, 2021, Protecting Public Health and the Environment and Restoring Science to Tackle the Climate Crisis 
    • Executive Order 14009 of January 28, 2021, Strengthening Medicaid and the Affordable Care Act 
    • Executive Order 14070 of April 5, 2022, Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage 
    • Executive Order 14075 of June 15, 2022, Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals 
    • Executive Order 14087, of October 19, 2022, Lowering Prescription Drug Costs for Americans 
  • Direct the Office of Management and Budget (OMB), the Attorney General, and Office of Personnel Management (OPM) to “coordinate the termination of all discriminatory programs,” including diversity, equity, and inclusion (DEI) programs, policies, and activities in the federal government. 
  • Combat “illegal private-sector diversity, equity, and inclusion (DEI) preferences, mandates, policies, programs, and activities.” 
  • Freeze federal rulemaking until department heads appointed or designated by the president can review and approve the rules and withdraw rules that have been sent to but not yet published in the Federal Register so they can be reviewed. 
  • Establish and implement the Department of Government Efficiency (DOGE) as a temporary organization within the Executive Office of the President that reports to the White House Chief of Staff. Executive agencies are directed to establish DOGE teams of at least four employees. DOGE is intended to modernize Federal technology and software to maximize governmental efficiency and productivity. 
  • Require OMB, OPM, and DOGE to submit a plan within 90 days to reduce the size of the federal government’s workforce through efficiency improvements and attrition. 

Developments on the Federal Funding Pause 

Notably, the White House OMB issued a memo (Temporary Pause of Agency Grant, Loan, and Other Financial Assistance Programs) on January 27, 2025, to all agencies with instructions to temporarily pause and provide a comprehensive analysis of all activities related to obligation or disbursement of federal financial assistance programs that EOs may affect. On January 29, 2025, the administration retracted the directive for a temporary pause on federal payments, though reiterated it will continue to review federal funding. 

Though it is customary for a new administration to pause communications, regulatory activity, and new funding opportunities as incoming political appointees are confirmed and policy agendas are solidified, the breadth of the federal funding pause exceeds prior orders. The first lawsuit was filed on January 28, and a federal judge for the US District Court for the District of Columbia quickly issued a temporary stay on the federal funding pause until at least February 3, 2025, while she considers arguments in the case. 

The now-rescinded January 27 memo was scheduled to take effect at 5:00 pm ET on January 28, 2025, to give the Trump Administration “time to review agency programs and determine the best uses of the funding for those programs consistent with the law and the President’s priorities.” According to the memo, the pause did not apply to Medicare or Social Security payments. In a subsequent document, OMB further clarified that “mandatory programs like Medicaid and SNAP [the Supplemental Nutrition Assistance Program] will continue without pause.” 

What to Watch: Executive Actions and Budget Reconciliation 

The Trump Administration has indicated that federal programs and funding should be aligned with his administration’s priorities. Healthcare stakeholders should be prepared for additional scrutiny of future funding awards. 

Meanwhile, congressional Republicans are preparing to quickly leverage the budget reconciliation process to pass legislation related to several priority areas, including taxes, immigration, and domestic energy production (see Spotlight on Congress: Budget Reconciliation Update). Budget reconciliation provides a rare opportunity to pass significant healthcare legislative changes on a party-line basis. House Republicans have begun to develop their menu of healthcare options, which range from changes to the ACA premium tax credit structure, expanding Health Savings Accounts, and changes in Medicaid financing and eligibility. 

In a January 2025 webinar, experts from Leavitt Partners, an HMA company, Liz Wroe, Sara Singleton, and Laura Pence discussed the potential health policy priorities of the Trump Administration, the implications of reconciliation for healthcare stakeholders, and the challenges and opportunities presented while navigating this expedited process. 

Navigating Change 

HMA experts are working with federally funded entities to quickly analyze their federal awards and plan for the next phase of federal agency actions and oversight. HMA companies also help healthcare stakeholders seeking to inform, shape, prepare for, and implement federal policy changes. Organizations seeking to influence the outcome of these policy debates and to thrive in a dynamic legislative and regulatory environment must have the most up-to-date information, informed by partners that understand the processes and the underlying policies under consideration. 

HMA experts provide additional complementary services, including analyses to predict how the Congressional Budget Office will score the costs or savings of specific policies. Especially in the reconciliation environment, the budgetary impact of particular policies can significantly influence their likelihood of passage. 

Connect with Us 

To learn more about the these policy changes and the impact on your organization, watch our January 2025 policy webinar and contact one of our featured experts below.

Blog

CMS Approves CA’s State Plan Amendment for Dyadic Care Authorizing Payment to FQHCs at Fee-for-Service Rates for Dyadic Care

Read Blog

On January 6, The Centers for Medicare & Medicaid Services (CMS) approved Medicaid State Plan Amendment (SPA) #23-0010. The SPA authorizes the California Department of Health Care Services Service (DHCS) to use an alternative payment methodology (APM) to pay Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and Tribal Health Programs at the Medi-Cal fee-for-service (FFS) rate for dyadic services. FQHCs and RHCs will receive a separate payment for dyadic services in addition to their standard prospective payment system (PPS)/all-inclusive payment rates in certain circumstances. This SPA is retroactively effective to March 15, 2023.

Key provisions are as follows:

  • California’s new set of dyadic benefits supports relationship-based caregiver and family surveillance and family-based interventions that bolster child development, recognizing the importance of the parent/caregiver and child dyad to support healthy child development. Dyadic health care services are ideally provided in the context of routine well child care in pediatric settings, meeting families where they regularly receive health care and related services.
  • Services are linked to a child’s Medi-Cal coverage, providing a basis for revenue recovery for primary care pediatric settings and for cases in which the parent/caregiver may not be a Medi-Cal beneficiary.
  • Services are exempt from the same day exclusion applied to FQHC and RHC settings. If FQHCs or RHCs have met their visit per day limit, then dyadic services provided to Medi-Cal-eligible members (children or parents/caregivers) will be reimbursed at the FFS rate. Any dyadic services that are provided to a non-Medi-Cal-eligible parents/caregivers for the direct benefit of Medi-Cal-eligible children will be reimbursed at the FFS rate.
  • Payment for dyadic FQHC and RHC services will be reimbursed at the applicable FFS rate in addition to Medi-Cal member visits, which are reimbursed at the applicable PPS rate.

In addition, the dyadic care benefit provides a pathway for families to access additional supports via the new family therapy benefit. Family therapy is a psychotherapy service that managed care plans provide under Medi-Cal’s Non-Specialty Mental Health Services benefits. Family therapy services support members younger than age 21 to receive up to five family therapy sessions before a mental health diagnosis is required. More importantly, children and youth (younger than age 21) may receive family therapy without the five-visit limitation if they (or their parents/caregivers) demonstrate certain risk factors, including separation from a parent/caregiver because of incarceration, immigration status, or death; foster care placement; food insecurity; housing instability; exposure to domestic violence or trauma; maltreatment; severe/persistent bullying; and discrimination.

Health Management Associates (HMA) has been proud to partner with HealthySteps, as a DHCS-recognized model, to provide an evidence-based (APL 22-029 (ca.gov) approach to implementing the new dyadic care benefits. Contact our experts below to learn more.

Blog

CMS Releases Final 2026 Marketplace Benefit and Payment Parameters

Read Blog

Trump Administration and Congress to Consider Policy Changes

This week, our In Focus section reviews the final Notice of Benefit and Payment Parameters (NBPP) for 2026. The Centers for Medicare & Medicaid Services (CMS) rule, released January 13, 2025, describes the policy and payment parameters for issuers that participate in federally facilitated and state-based marketplaces in 2026.

The NBPP is particularly notable given that marketplace enrollment is at an all-time high. Last week, CMS reported that 24.2 million people joined a marketplace plan during 2025 Open Enrollment, exceeding last year’s historically high enrollment levels by more than 2 million people.[1] With millions more individuals covered in the individual market, this final rule presents several opportunities for the healthcare industry to improve the well-being of covered individuals and families and the financial health of participating organizations.

Marketplace policies are under scrutiny, however, from new Trump Administration officials and congressional leaders. Subsidies, eligibility, and reimbursement are among the topics receiving the greatest attention.

Key highlights from the final rule and considerations for stakeholders in the changing healthcare landscape follow.

Consumer Protections

The final rule further strengthens consumer protections, consistent with the policies advanced during the Biden Administration. CMS finalized policies to achieve the following:

  • Protect consumers from agents and brokers seeking to make unauthorized changes to their healthcare coverage
  • Allow the agency to take enforcement actions against lead insurance agents for violations of marketplace standards
  • Expand the agency’s authority to immediately suspend an agent or a broker’s ability to make transactions within the marketplace if the information creates an unacceptable risk to the accuracy of marketplace eligibility determinations, operations, applicants, or enrollees, or marketplace IT systems
  • Update the model consent form, which helps agents and brokers document consent from consumers to assist with their marketplace enrollments and submission of marketplace eligibility applications

Revisions to Marketplace User Fees

The enhanced premium tax credits are the driving force behind the increase in nationwide marketplace enrollment to more than 24 million today from 11.4 million in 2020. If not extended, or if Congress takes no action by July 31, 2025, CMS will increase the user fees collected to pay for administration of HealthCare.gov as follows:

  • Increase fees to 2.5 percent of monthly premiums in 2026 for federally facilitated marketplaces (FFM) states, up from 1.5 percent in 2025
  • Increase fees to 2.0 percent of monthly in 2026 for state-based marketplaces on the federal platform (SBM-FPs)—up from 1.2 percent in 2025

CMS also is finalizing an alternative set of user fee rates. If enhanced premium tax credit subsidies are extended through the 2026 benefit year by July 2025 at the current or a higher level the following user fees rates will apply:

  • 2 percent for FFM states
  • 1.8 percent for SBM-FPs

CMS originally proposed a March 2025 subsidy extension deadline for activating the lower user fee. Insurer should take into account the higher user fees when setting their 2026 premiums—SBMs as they finalize their 2026 user fee levels and FFM states considering the costs of staying in Healthcare.gov or transitioning to a SBM.

Premium Payment Threshold Options

CMS finalized new options for insurers to avoid triggering late payment grace periods for members who make most but not all their premium payment. The new threshold options are intended to minimize termination of coverage for people who owe small amounts. The options include:

  • For the first month’s premium payment to effectuate coverage—or binder payments—the only option is to use a net premium threshold as low as 95 percent
  • For all other premium payments after the first month’s payment, the options include:
    • Net premiums as low as 95 percent or a fixed dollar threshold of up to $10
    • Gross premiums percent of as low as 98 percent or fixed dollar threshold of up to $10

Fixed dollar thresholds will be adjusted for inflation.

Information Sharing and Transparency

CMS is finalizing policies designed to increase transparency and promote program improvements by publicly releasing state marketplace operations data, including spending on outreach and additional open enrollment customer service metrics, such as for call center performance surveys and website visits. The final rule clarifies that CMS will not publicly release each SBM’s annual State-based Marketplace Annual Reporting Tool (SMART), a reversal from what was proposed.

In addition, CMS is finalizing that it will share aggregated, summary-level Quality Improvement Strategy (QIS) information publicly on an annual basis starting January 1, 2026, with data submitted during the 2025 qualified health plan application period.

What’s Next/Key Considerations

The new leadership at the US Department of Health and Human Services (HHS) and CMS will likely conduct a thorough review of these payment and policy changes. In consideration of potential repeals or modifications, states and marketplace plans will need to consider the following:

  • Uncertainty around extending or modifying Affordable Care Act subsidies
  • Potential statutory changes approved by Congress and regulatory changes from the Trump Administration
  • Review of existing operations and policies in light of the new regulations and the changing policy environment

Connect With Us

Health Management Associates experts support states, managed care organizations, consumer groups, and other interested stakeholders to achieve success in the operation of and participation in the marketplaces. Our team has the broadest historical perspective on the challenges and opportunities in this market and can support every step of the planning and execution processes to optimize markets as they continue to evolve in the coming months and years. If you have questions or want to discuss the final rule, contact our experts below.

[1] Centers for Medicare & Medicaid Services. Over 24 Million Consumers Selected Affordable Health Coverage in ACA Marketplace for 2025. January 17, 2025. Available at: https://www.cms.gov/newsroom/press-releases/over-24-million-consumers-selected-affordable-health-coverage-aca-marketplace-2025.

Blog

Federal election impacts on Ohio Medicaid

Read Blog

Ohio Medicaid is no stranger to change. Over the last several years, there have been several broad policy changes, from a new managed care system, to new programs like OhioRISE, to an expansion of MyCare Ohio. And, during this time, there have been complicating factors like the covid-19 public health emergency and the resultant impact of inflation on the basic delivery of services and care. Now, as the Trump administration comes in for the second time, questions arise as to what to expect in Medicaid policy and how it may impact Ohio.

While it’s often overlooked, federal rule making has a significant impact on the operations of states. Just in the last couple of years, the Biden Administration has implemented policies including:

  • The Access rule, such as the 80/20 policy, implementation timelines, and other questions regarding Home and Community Based Services waivers that states and certain stakeholders elevate to the Centers for Medicare & Medicaid Services (CMS).
  • The Managed Care rule, which addresses Medicaid managed care access, financing, and quality, including strengthening standards for timely access to care and states’ monitoring and enforcement efforts.
  • The Long-Term Care Facility (LTC) Staffing rule requires minimum staffing standards for nursing facilities.
  • Two rules streamline Medicaid enrollment and renewal processes for the Medicare Savings Program (MSP) and for Medicaid, CHIP and the Basic Health Program. Each rule is expected to increase Medicaid enrollment by about one million people.

These rules are set to be implemented over several years. The Trump Administration could delay implementation of certain provisions, which would eliminate regulations while rolling back enrollee protections, payment transparency, and improved access. Alternatively, the Trump Administration could adjust their enforcement strategy or issue new regulations that would undo or augment these final regulations.

Beyond regulation, there is still the potential for fundamental policy change to the program’s financing. Notably, the concept of block grants or per-capita caps has reemerged as a potential option, where states would no longer receive federal “match”, but rather a fixed amount based on historical averages. In fact, Energy and Commerce Chair Brett Guthrie has already identified per capita caps as an area of active conversation in the House Republican Caucus.

Making a fundamental, national change in the financing arrangement of Medicaid would require an act of Congress. Many think this movement away from a traditional reimbursement structure was one of the main reasons for the failure to repeal the Affordable Care Act during the first Trump administration. Notably, as Ohio is a “recipient” state, meaning it receives more in federal taxes than it provides for the Medicaid program, this could significantly impact the long-term financial stability in future state budgets. Often, this challenge is why block granting is usually associated with additional state powers around curbing enrollment, services and coverage, so states may more easily cut the program to accommodate tighter financing.

Depending on how all of these changes would unfold, Medicaid programs, including Ohio’s may have to adopt their systems to accommodate. However, the Trump administration may also pursue greater flexibility for states to design and innovate in Medicaid in ways that are consistent with their goals. This could include greater flexibility to limit covered services, raise cost-sharing requirements, limit enrollment or require more frequent determination of eligibility. There may also be programmatic refocusing away from initiatives which center health equity and expanded coverage, including alternatives to “Medicaid expansion”, as well as a fundamental reorientation of the use of waivers.

Speaking of waivers, there is likely going to be a dramatic change in the way waivers are applied and executed. This can include, but is not limited to, waivers that test new policies the prioritize cost-cutting measures over access and coverage, including waivers which change how the Medicaid expansion group is managed in states. Included in this are “Work Requirement” waivers, something Ohio is currently in the process of submitting. While examples from other states have shown that such waivers are often costly to operate and ultimately have the impact of decreasing coverage, the Trump administration and many policymakers see these requirements as a way to ensure labor force participation. Though there is evidence to suggest coverage, alone, increases economic mobility,

As Ohio providers, plans and policymakers gear up for the next state budget, the landscape of Medicaid policy will be something to pay attention to. While Medicaid represents nearly 48% of the total state budget, half of that is from the federal government. What’s more, nearly 1 in 3 Ohioans rely on the program, disproportionately in rural communities, and it supports Ohio’s second largest industry in healthcare. Make sure you stay on top of the latest updates to the program in Ohio and beyond and sign up for HMAs Weekly Roundup.

Ohio Health Policy Snapshots

Sign up for Ohio Health Policy Snapshots delivered right to your inbox

Schedule a consultation
Ready to talk?