Health Plan Weekly
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A Closer Look at the U.S. Mental Health Provider Shortage
The U.S. health care system is currently ill-equipped to meet the high and growing need for behavioral health services, and states need to take efforts to mitigate related workforce shortages, according to a recent report by Georgetown University’s Center on Health Insurance Reforms (CHIR).
As of August 2024, more than a third of Americans lived in a federally designated mental health professional shortage area. The inadequate behavioral health workforce — referring to a range of clinicians and paraprofessionals who specialize in delivering or supporting mental health and substance use disorder treatments — disproportionately impacts rural and marginalized communities. Over 45% of rural counties across the nation did not have practicing psychologists in 2021, compared to 16% of urban counties.
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Medicare, Medicaid Coverage of Obesity Drugs Would Add $40B in Government Spending
Medicare Part D and Medicaid coverage of anti-obesity medications would increase federal and state spending by $40 billion over 10 years, CMS estimated in a proposed rule released on Nov. 26, even though Part D plans could define the disease for coverage decisions.
The policy long sought by drug manufacturers and patient groups is part of the 2026 Policy and Technical Changes to the Medicare Advantage and Medicare Part D Programs proposed rule.
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News Briefs: Proposed Rule Would Tweak Medicare Advantage Regs
CMS on Nov. 26 issued a proposed rule that would make various changes to the regulations governing Medicare Advantage plans, as well as increase access to anti-obesity medications for Medicare and Medicaid beneficiaries. Starting in 2026, CMS is proposing to reinterpret the Medicare statute “to no longer exclude anti-obesity medications for the treatment of obesity from coverage under Medicare Part D and to require Medicaid programs to cover these medications when used to treat obesity.” If finalized by the Trump administration, the rule would greatly increase Medicare and Medicaid beneficiaries’ access to FDA-approved weight loss medications such as Wegovy (semaglutide) and Zepbound (tirzepatide). The rule would also limit the use of prior authorization and internal coverage criteria in Medicare Advantage and Part D plans as well as “increase guardrails on the use of artificial intelligence to protect access to health services.” In addition, the agency is seeking to make upgrades to the Medicare Plan Finder website, including requiring MA organizations to make their entire provider directory available and making it easier for consumers to compare MA plans. Ceci Connolly, president and CEO of the Alliance of Community Health Plans, said in a Nov. 26 statement that “we are deeply concerned with the proposed coverage expansion of weight loss drugs in Medicare and Medicaid” and added “the proposed expansion is irresponsible without further analysis and stakeholder engagement.”
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Aetna Expects ACA Exchange Membership to Drop at Least 20% in 2025
As CVS Health Corp. looks to revamp its struggling Aetna health insurance business, the company plans to significantly reduce its Affordable Care Act exchange footprint and raise premiums. Speaking at the Wolfe Research Healthcare Conference on Nov. 19, CVS Chief Financial Officer Thomas Cowhey acknowledged that Aetna increased its premiums for exchange plans next year by “double-digit” percentages because it is losing $750 million to $800 million in that business due to mispricing this year. The company is also exiting unprofitable markets.
While Aetna’s financial results do not break out how many people are enrolled in exchange plans, CVS CEO David Joyner said during the firm’s third-quarter earnings call on Nov. 6 that exchange membership increased significantly this year. But he also said the segment’s “performance is unacceptable” because of “miscalculations during the 2023 bid processes.” As such, Aetna changed its pricing strategy for 2025 and expects its exchange membership will decrease by 20% to 25% next year, according to Cowhey.
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With Oz, Kennedy Nominations, Uncertainty Abounds for Health Insurers
Now that President-elect Donald Trump has revealed his picks for two top health officials — Mehmet Oz, M.D., as CMS administrator and Robert F. Kennedy Jr. as HHS secretary — the multibillion-dollar industries regulated by those agencies are scrambling to wrap their heads around what policy changes could result from Oz and Kennedy’s wellness-focused, antiestablishment views.
So far, the consensus appears to be that Medicare Advantage plans could face a much friendlier regulatory environment under Oz, who in the past has voiced support for a “Medicare Advantage for All” system. But Oz’s views on the Affordable Care Act and Medicaid are tougher to pin down, and Kennedy’s stance on the managed care industry is even fuzzier, since he is perhaps best known for his vaccine skepticism.
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