Key Takeaways
- Republicans in Washington are focusing on health policy as part of a broad effort to address voters’ concerns about affordability heading into the 2026 midterms.
- Two weeks ago, the White House released President Donald Trump’s Great Healthcare Plan and called on Congress to pass the priorities it outlines. Although the proposal contains only broad strokes and is unlikely to be successfully taken up on Capitol Hill, it does signal Republicans’ current health policy priorities.
- Meanwhile, Congress last week released its final package of appropriations legislation to finish funding the government for fiscal 2026, and it included long-sought reforms to pharmacy benefit manager (PBM) practices and provisions to address hospital reimbursement at off-campus locations. Those proposals initially appeared on track to be signed into law this month, but the uproar over two deadly shootings by federal agents in Minnesota now has passage in doubt.
On Jan. 15, 2026, the White House released a fact sheet outlining healthcare priorities (the Fact Sheet) and calling on Congress to turn those priorities into law. Congress is also including a health policy package in appropriations legislation to finish funding the government for fiscal year 2026 and prevent another shutdown at the end of January (the Appropriations Bill).
The focus on health policy is part of Republicans’ push to address affordability, as consumers continue to have deep concerns about everyday costs throughout the economy. Republicans are also motivated to present their own health ideas as insurance premiums increase for Affordable Care Act (ACA) plans following the expiration of enhanced tax credits for certain enrollees.
Below is a high-level summary of these policy developments, potential regulatory implications and considerations for healthcare stakeholders.
Congressional Appropriation Legislation: PBM Reforms and Health Policy Extenders
Congress Includes Health Policy Package in Appropriations Legislation
Following last autumn’s long government shutdown, Congress has taken up fiscal year 2026 appropriations legislation in several tranches. The last group of bills, referenced above as the Appropriations Bill, passed the House and now heads to the Senate, and it includes a range of health policy provisions. The health package in the Appropriations Bill is the product of weeks of negotiations among bipartisan health leaders in Congress.
Prior to the weekend, the Appropriations Bill had bipartisan support and was set to be approved by the Senate and signed into law this week. However, the recent deaths of two Americans in shootings by federal immigration agents in Minnesota have sparked a serious political crisis and collapsed support for the legislation, which included funding for the Department of Homeland Security (DHS), which employs the agents. The next steps for both the health policy provisions and the broader Appropriations Bill are undecided, but the legislation is stalled and a partial government shutdown appears likely when current funding for DHS and several other agencies expires on Jan. 31.
Regardless of the outcome of this week’s events and a likely shutdown, Congress is likely to revisit these policies in future legislation.
The most notable piece of the health package targets PBMs, which have faced years of bipartisan criticism. Starting in 2028, PBMs would be required to “delink” their Medicare compensation from drugs’ list prices. This means instead of being paid a percentage of the drug’s price, PBMs would receive a flat fee. PBMs would also be required to pass through to employer plans any savings they negotiate with manufacturers and to report information to the government and plan sponsors regarding drug costs and out-of-pocket spending by enrollees.
The Appropriations Bill also requires hospitals’ off-campus outpatient departments to have separate identification numbers for reimbursement purposes. Advocates for “site-neutral” hospital payments sought this provision hoping it would help payors challenge differences between reimbursements for services performed in hospital outpatient departments and similar ones performed in physician offices.
Finally, the Appropriations Bill renews a wide range of expiring health policies, including Medicare telehealth authorities and hospital-at-home programs and funding for community health centers and the National Health Service Corps, and averts cuts to disproportionate-share hospitals. It also boosts funding for implementation of the No Surprises Act, the 2020 law that aims to address surprise medical bills.
White House: Trump’s Great Healthcare Plan Summary
Locking in Lower Drug Price Deals and Increasing OTC Availability
The Fact Sheet asks Congress to codify the most-favored-nation deals that the administration has recently made with large drug manufacturers. The Fact Sheet explains that “voluntarily negotiated deals with HHS [Health and Human Services]/CMS [the Center for Medicare & Medicaid Services] will be grandfathered,” presumably meaning that Congress should deem those deals compliant with whatever statutory framework Congress enacts, without renegotiation.
The administration also asks Congress to increase the over-the-counter availability of “safe pharmaceutical drugs” to increase consumer choice and competition, strengthen price transparency, and reduce “the need for costly and time-consuming doctor’s visits.”
Direct Payments, Cost-Sharing Reduction Program and PBMs
The administration calls on Congress to dismantle the subsidy structure under the ACA by rerouting “billions in extra taxpayer-funded subsidy payments ... directly to eligible Americans” so they can buy their own health insurance. The Fact Sheet does not detail who would qualify or how funds would be distributed. The ACA-enhanced subsidies expired on Dec. 31, 2025. Open enrollment for ACA plans ended the same day the Fact Sheet was released, reflecting the White House’s pressure to address the issue after lawmakers deadlocked on negotiating an extension.
The Fact Sheet also proposes a cost-sharing reduction program. Cost-sharing reduction plans were a core part of the ACA’s architecture, reducing deductibles and copayments for lower‑income enrollees in Silver-tier plans.
The outlined plan calls on Congress to target PBM payment practices – the one piece of the plan that Congress has a strong chance to deliver to Trump’s desk in the near term. The same day, Jan. 15, 2026, the Federal Trade Commission filed a Joint Status Report in its administrative action against the nation’s largest PBMs, outlining ongoing discovery into financial arrangements, accounting practices, out-of-pocket costs and patient affordability programs.
Holding Insurance Companies Accountable
The Fact Sheet also emphasizes insurance market transparency and aims to empower health insurance consumers to make educated plan purchasing decisions through a “plain English” insurance standard. According to the administration, this standard would require insurers to present pricing and coverage information in clear and easily understandable language. The Fact Sheet calls on Congress to require insurance companies to prominently publish rate and benefit comparisons on their websites, including the percentage of revenue spent on claims versus administrative costs and profits, claim denial rates, and average wait times for routine care.
Maximizing Price Transparency
The Fact Sheet’s final component focuses on maximizing price transparency by calling on Congress to require any healthcare provider or insurer that accepts public insurance to publicize their pricing and fees at their place of business. This increased transparency is intended to allow consumers to avoid unexpected bills and fees, thus allowing more informed healthcare consumption.
Price transparency has been a focus of legislation and policy under the past several administrations. In 2010, the ACA required states to post proposed rate increases for insurance plans, invited public comment and mandated rate review transparency. In 2019, President Trump signed an Executive Order pushing for more transparency across hospitals and insurers. At the end of 2020, the Department of Health and Human Services, the Treasury Department, and the Department of Labor (the Departments) published the Transparency in Coverage final rule requiring insurers to publish cost-sharing and rate information, and the No Surprises Act was signed into law. Since that time, the Departments have published subsequent final rules to improve price transparency and implement the No Surprises Act.
If you have questions or would like to discuss how this alert may impact your business, please reach out to our Healthcare team.
