Illustration: Allie Carl / Axios
The seismic changes unleashed by the reconciliation bill and the insurance coverage losses it will bring are bound to touch every corner of health care. And the lobbying around the package over the last half year yielded clear winners and losers.
- Here's a look at how the biggest players fared:
Winners
PBMs
CVS Caremark, Express Scripts and OptumRx went from staring down a bipartisan overhaul of their business practices that almost made it into law in December to a narrower set of changes in the House-passed reconciliation bill that were subsequently dropped in the Senate.
- Some PBM overhauls, like an effort to ban spread pricing in Medicaid, fell to Byrd Rule parliamentary challenges.
- Rep. Buddy Carter, the industry's No. 1 antagonist, is also stepping down as House Energy and Commerce health subcommittee chair.
- Still, plenty of members in both parties are unlikely to let the push for changes die. And President Trump has expressed interest in cutting out "famous middlemen" in an effort to lower drug prices.
Half a loaf
Doctors
Physicians will be getting a 2.5% one-year fix to their Medicare reimbursements via reconciliation. But that short-term measure means they'll have to fight for another funding patch in 2027 to offset automatic cuts that are due to take effect.
- Rep. Greg Murphy, who's been vocal about the need to permanently fix the Medicare physician payment system, told reporters this week that the 2.5% rate may not be enough to make up for the cuts that have already taken effect.
- Doctors are also concerned about the Medicaid cuts in the bill and a rise in uncompensated care.
Pharma
Drugmakers dodged the biggest threat they were facing: the inclusion of Trump's "most-favored nation" pricing policy in the bill. That was never a given, considering widespread opposition from GOP lawmakers to what they saw as the equivalent of government price-setting.
- But the industry didn't get some of its main asks, like a PBM overhaul or language addressing the "pill penalty" in the IRA, which would have extended the time small molecule drugs have before they face Medicare price negotiations.
- Lawmakers did include a broader exemption from negotiations for orphan drugs, which was a priority for BIO.
Losers
Hospitals
Hospitals are taking a major hit from the bill's Medicaid cuts and ACA marketplace changes, which will mean more uninsured people and more uncompensated care.
- The American Hospital Association said the bill will mean "longer waiting times in emergency departments and for other essential services, and could ultimately lead to facility closures, especially in rural and underserved areas."
- A $50 billion fund for rural hospitals is intended to soften the blow, but hospitals say a new fund is inadequate to make up for the extent of the cuts to the underlying programs.
Insurers
Millions of people are likely to lose their health insurance from Medicaid work requirements and the tightening of eligibility rules for Medicaid and the ACA.
- Republicans also didn't include an extension of enhanced ACA tax credits that are expiring at the end of the year.
- AHIP is warning that the combined effects could bring "the biggest rollback in health care coverage in the country's history" while destabilizing state Medicaid programs and creating an individual market that has less choice and higher premiums.
- But Medicare Advantage insurers dodged a bullet when negotiators left out Senate HELP Committee Chair Bill Cassidy's proposal to crack down on MA upcoding.
- Insurers also got some reprieve when ACA cost-sharing reduction funding was dropped from the final bill, preventing a last-minute disruption for planning next year's premiums.
The biggest stakeholders
The newly uninsured
The CBO estimates 11.8 million people will become uninsured from the bill. Many will lose coverage from new Medicaid work requirements. Republicans say able-bodied people should be working, but Democrats counter that many people who are working will lose coverage from new red tape.
