Washington is gearing up, once again, to tackle the cost of health care. The current Administration has put competition, accountability and lower costs at the cornerstones of its health care agenda. That’s a welcome shift from defending the status quo. And it creates an opening for a long-overdue conversation. Who is best positioned to deliver on the promise of value?
Built Different
ACHP member companies are community-based and nonprofit by design, reflecting the unique structure of the payer-provider partnership model. When a health plan serves a defined region, its consumers are neighbors, family and friends. Without the need to distribute profits to shareholders, every dollar goes into better care, lower premiums and the local community.
Back in 2020, ACHP published Roadmap 2030, a comprehensive action plan to make health care more affordable, higher quality and competitive. The policies we called for then are the ones gaining traction now. We didn’t pivot to meet the moment; we created it.
Medicare Advantage: Seniors Deserve Better
Nowhere is ACHP’s reform fingerprint more visible than in Medicare Advantage. Rather than defend the status quo, ACHP has worked tirelessly to continuously improve this popular program. CMS’ most recent Medicare Advantage regulation eliminated the flawed Health Equity Index, restored the reward factor for consistent high-quality health plans and realigned the Stars program toward patient experience and health outcomes rather than documentation. These are the tangible results of years of steady advocacy via our MA for Tomorrow initiative.
But the work is far from finished. Our risk adjustment analysis documented wide disparities between the large nationals and ACHP’s regional plans. The largest insurers use coding practices that maximize payment, regardless of whether care was delivered. These massive risk adjustment payments waste tens of billions of taxpayer dollars each year. It’s a structural failure rife with loopholes and fixing it is essential to a genuinely competitive MA market.
“The Administration’s relentless focus on MA is welcomed, but for the change to be reflected in seniors’ wallets, we must get risk adjustment right. Nonprofit, regional plans can only compete on quality, provider services and benefits if the payment model rewards care, not coding.”— Ceci Connolly, President and CEO, ACHP
Drug Pricing: Common-Sense Reforms Are Within Reach
Americans pay more for medications than patients in any other developed country. Not because the drugs are better, but because the system rewards manufacturer profits and drug middlemen over affordability for consumers. Here’s just a taste of the ACHP reform agenda:
• Eliminate direct-to-consumer advertising: An easy win. The U.S. and New Zealand are the only two countries that allow drugmakers to advertise prescription medications directly to patients. In 2023, the top 10 manufacturers spent nearly $14 billion in ads for expensive, brand-name drugs. Banning tax deductions for direct-to-consumer advertising would save about $137 billion over ten years. This has broad, bipartisan support. Let’s get it done.
• Biosimilars: Ready-made win. According to The Association for Accessible Medicine’s Biosimilar Council, these FDA-approved alternatives to expensive biologic drugs have saved patients and the health care system nearly $56.2 billion since 2015. The barrier to entry isn’t scientific; it’s all regulatory. The Biosimilar Red Tape Elimination Act would remove the burdensome interchangeability designation that slows biosimilars to market despite their proven safety and effectiveness. ACHP strongly supports its passage.
• GLP-1s: Offering GLP-1s as a cure-all and mandating coverage at current prices would be fiscally reckless. Getting the right treatment to the right patient at the right price; that’s the standard we’re holding to.
The ACA and Medicaid: The Coverage Chaos
ACHP member companies consistently rank among the top performers in Medicaid and ACA Marketplace because they treat enrollees as real people, not just claims to be processed. That track record informs our policy positions.
More than 23 million Americans rely on Marketplace coverage, and regional health plans are often the highest-quality option in their communities. The expiration of enhanced premium tax credits was a real setback for affordability. Early data suggests many working Americans are reducing benefits or dropping coverage entirely. As the uninsured and underinsured rates rise, hospitals will be hit with higher uncompensated care burdens.
ACHP recently submitted a letter to CMS outlining priorities to protect market stability and strengthen consumer protections. There is more work to do to ensure coverage is broadly accessible.
Envisioning Tomorrow’s Health Care, Today
In an era when competition, accountability and cutting sky-high costs are driving the policy conversation in Washington, policymakers are hungry for bold ideas that will meaningfully improve Americans’ health care. They need look no further than ACHP and its nonprofit, regional health plans to understand how commonsense reforms will lower the prices families pay for their medicines, create a strong and competitive Medicare Advantage program and ultimately, lead to a more effective and higher value health care system today and for generations to come.
