Sweeping changes that congressional Republicans made to the Affordable Care Act and Medicaid are starting to take effect, fueling an election-year blame game over coverage losses.

Why it matters: A rise in the uninsured rate will put more stress on the health system and ratchet up concerns about health costs in an election year where affordability is voters' biggest concern.

Driving the news: The changes are hitting home, with about 1.2 million fewer people signed up for ACA coverage compared with a year ago, following Congress' refusal to extend enhanced subsidies.

• Nebraska this month also became the first state to impose new work requirements on Medicaid recipients who enrolled under the ACA expansion.

By the numbers: Wakely Consulting Group found that 14% of enrollees did not pay their first ACA premium in January. It estimated that 2026 enrollment will end up being 17% to 26% lower than last year.

• Insurers in some states are reporting drops in enrollment as high as 20% to 30%, while other states are stepping in to offer additional financial help to limit the losses, according to an insurance industry source.

What they're saying: "We don't have full data yet but all signs point to a substantial drop in enrollment with the expiration of the enhanced premium subsidies," said Larry Levitt, executive vice president for health policy at KFF, estimating "several million" fewer enrollees.

The coverage losses already are seeping into campaign messaging ahead of the midterm elections as Democrats try to flip control of the House.

• The Democratic Congressional Campaign Committee took aim at Rep. Nick Begich (R-Alaska) last week for voting against extending the enhanced ACA tax credits, saying premiums have risen 58% on average.
• It similarly targeted Colorado GOP Reps. Jeff Crank and Gabe Evans for their votes to cut Medicaid in last year's Republican tax-and-spending bill and refusal to extend ACA subsidies.

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The Supreme Court kept in place a freeze yesterday on new restrictions for dispensing the widely used abortion pill mifepristone, allowing the continued mail-order prescribing of the drug.

Why it matters: The extension, which runs through 5pm Thursday, provides a reprieve for pharmacies, telehealth companies and clinicians caught up in the latest legal tussle over accessing the pill.

Driving the news: Justice Samuel Alito extended a stay he granted a week ago in response to requests from drugmakers Danco Laboratories and GenBioPro to restore access to mifepristone via teleprescribing and the mail.

• Anti-abortion advocates have been calling for a rollback of a Biden administration policy that expanded access to mifepristone and removed a requirement that patients see a provider in person before getting the medication.
• The 5th U.S. Circuit Court of Appeals earlier this month sided with Louisiana in a case challenging the Biden administration rules.
• Drug companies have argued in legal filings that the decision had a destabilizing effect on the FDA's regulation of drugs.

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Optum Rx — which includes the pharmacy benefit manager of health care conglomerate UnitedHealth Group — is shifting to a business model that no longer ties its compensation to drug list prices or the volume of prescriptions.

The big picture: PBMs are responding to increasing political pressure and criticisms that their business practices are contributing to high prescription drug costs.

Driving the news: Optum said yesterday it would move to a fee-based system starting in 2027 for negotiating drug purchases for commercial health plans and employers, with clear disclosure of payments it receives from drugmakers.

• It's also eliminating "spread pricing" — a practice in which a PBM charges a health plan more than it pays a pharmacy for a drug.
• Optum CEO Patrick Conway told Axios the pivot reflects a commitment to added transparency and lower costs by offering "a simpler and more predictable pharmacy system."

It's the latest in a series of changes Optum has announced — including passing 100% of drug rebates negotiated with manufacturers to its clients and dropping prior authorization requirements for some prescription drugs.

• The company also said yesterday that it's launching new digital tools aimed at helping consumers do price comparisons and know the cost of their drugs before they go to the pharmacy.

Nurses are using AI less frequently than physicians and many feel like they're being excluded from decision-making, according to survey data from scientific publisher Elsevier shown first to Axios.

Why it matters: Nurses are often where the rubber meets the road in health care. Without their buy-in and input, hospitals could spend on medical tools that don't actually help staff or patients.

State of play: Just 41% of nurses reported using AI tools frequently in a survey of almost 700 conducted last winter, compared with 57% of physicians.

• About half of those surveyed said the technology empowers them and 53% said AI currently improves patient care.
• 55% of nurses said they believe AI will save them time within the next two to three years — significantly less than the 70% of doctors who expect it will.

Between the lines: The use of AI in hospitals has become a friction point in some labor-management disputes over the past year. New York City nurses negotiated safeguards against AI in their contracts following a historic strike in February.

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💉 Health Secretary Robert F. Kennedy Jr. is driving a behind-the-scenes federal inquiry into vaccines, despite toning down his public comments. (NYT)

🦠 Some promising hantavirus treatments that had been shelved because of a lack of consistent funding could see a new influx of money for testing. (WSJ)

👦🏻 A pediatrics group issued the first new guidance on recess time for grade schoolers in more than a decade. (AP)