Federal Legislative & Regulatory Forces on Syam Adusumilli

The One Big Beautiful Bill

Sun, 15 Mar 2026 00:00:00 +0000

Signed on July 4, 2025, the One Big Beautiful Bill Act is the largest federal budget reconciliation law since the Affordable Care Act. Its health provisions are centered on Medicaid, where the savings are massive and the structural changes are permanent. But the law’s effects do not stop at the Medicaid boundary. The downstream pressure on dual eligible populations, state fiscal capacity, and the long-term Medicare financing environment makes OBBBA as much a Medicare story as a Medicaid one. This article maps the law’s health provisions and traces the cascade.

Summary: The One Big Beautiful Bill

Sun, 15 Mar 2026 00:00:00 +0000

Signed on July 4, 2025, the One Big Beautiful Bill Act is the largest federal budget reconciliation law since the Affordable Care Act. Its health provisions center on Medicaid, where the fiscal reductions are permanent and the structural changes generational. The downstream pressure on dual eligible populations, state fiscal capacity, and HI Trust Fund financing makes OBBBA as much a Medicare story as a Medicaid one.

The core of OBBBA’s Medicaid savings is a federal work requirement applied, for the first time at national scale, to adults enrolled through the ACA Medicaid expansion. Adults aged 19 through 64 must complete 80 hours per month of qualifying community engagement activities, with states required to verify compliance at application and at least every six months thereafter. The federal implementation deadline is January 1, 2027, with good-faith extensions available through December 31, 2028. CBO projects the work requirement provisions will reduce federal Medicaid spending by $326 billion over ten years and that 4.8 million adults will lose coverage by 2034. A compounding feature seals the coverage gap: individuals who lose Medicaid coverage through noncompliance are expressly ineligible for ACA Marketplace premium tax credits and have no federal subsidy pathway available. Arkansas’s 2018 attempt is the relevant precedent, where 18,000 people lost coverage before a court intervened and administrative error, not actual noncompliance, accounted for most disenrollments. Six-month verification cycles applied to more than 20 million expansion enrollees across 41 states represent an administrative volume with no federal precedent, and the December 2025 CMS guidance did not resolve the implementation complexity states face.

The Prior Authorization Divide

Sun, 15 Mar 2026 00:00:00 +0000

For nearly two decades, prior authorization was a defining feature of Medicare Advantage and largely absent from Traditional Medicare. A beneficiary who chose Original Medicare accepted lower benefits and higher cost-sharing exposure in exchange for freedom from utilization management. WISeR ends that deal for a targeted set of services and introduces a structural irony that has not gone unnoticed: an administration that has publicly criticized MA prior authorization practices for contributing to inappropriate denials is simultaneously building a PA program into fee-for-service Medicare. How the two regimes compare, and what the convergence signals for providers and beneficiaries, is the subject of this article.

Summary: The Prior Authorization Divide

Sun, 15 Mar 2026 00:00:00 +0000

WISeR launched January 1, 2026, introducing prior authorization into fee-for-service Medicare for the first time at scale. The timing is striking: the same administration that has publicly criticized MA prior authorization for contributing to inappropriate denials and upcoding pressure is simultaneously building a PA program into Traditional Medicare. How the two regimes compare, and what the structural differences reveal about where the policy pressure will land, is what the prior authorization divide is about.

Medicare Equity

Sun, 15 Mar 2026 00:00:00 +0000

The Health Equity Index was the most consequential equity incentive ever embedded in Medicare Advantage Star Ratings. It was finalized in 2024, renamed in April 2025, and proposed for elimination in November 2025. Before it ever produced a payment adjustment for the populations it was designed to benefit, the current CMS administration proposed to scrap it. The reversal is not a technical adjustment to the Star Ratings methodology. It is a signal about the direction of equity-focused policy in Medicare, and reading that signal accurately requires understanding what the HEI actually was, why the administration gave for removing it, and what the structural equity picture in Medicare looks like independent of any explicit policy framework.

Summary: Medicare Equity

Sun, 15 Mar 2026 00:00:00 +0000

The Health Equity Index was finalized in 2024, renamed in April 2025, and proposed for elimination in November 2025. Before it ever produced a payment adjustment for the populations it was designed to benefit, CMS’s current administration proposed to scrap it. The reversal is not a technical adjustment to the Star Ratings methodology. It signals the direction of equity-focused policy in Medicare under the current administration, and reading that signal accurately requires separating what the HEI was, why it was removed, and what the structural equity picture in Medicare looks like independent of any explicit policy framework.

Reading the Federal Regulatory and Legislative Calendar

Sun, 15 Mar 2026 00:00:00 +0000

Every article in this series describes policy that exists within a regulatory environment that is itself moving. Rate notices arrive in April. Proposed rules open in the spring, close comment periods in midsummer, and finalize in the fall. Congressional committees hold hearings, launch investigations, and sometimes pass legislation. The 119th Congress completed its reconciliation cycle with OBBBA in July 2025, and what remains of its legislative bandwidth in health care is contested and finite. This article maps the rulemaking calendar that will govern Medicare payment and program policy through 2027, the legislative environment that frames it, and the strategies available to plans, providers, and advocates for engaging the process while it is still open.

Summary: Reading the Federal Regulatory and Legislative Calendar

Sun, 15 Mar 2026 00:00:00 +0000

Every major policy development in this series exists within a regulatory environment that is itself moving. Rate notices arrive in April. Proposed rules open in spring, close comment periods in midsummer, and finalize in the fall. The 119th Congress completed its reconciliation cycle with OBBBA in July 2025, and the legislative bandwidth remaining for health policy is contested and finite. The 2026 and 2027 rulemaking cycles will resolve, or defer, most of the open policy questions that plan executives, health systems, and providers need to act on.

CMS Under Pressure

Sun, 15 Mar 2026 00:00:00 +0000

Every series in this publication assumes CMS can execute what it announces. That assumption requires examination. In 2025 and 2026, CMS is simultaneously launching WISeR across six states, extending AHEAD and Geo AHEAD through 2035, standing up ACCESS and BALANCE as new CMMI models, managing a complete risk adjustment overhaul, running the full annual MA and Part D rulemaking cycle, and implementing OBBBA’s Medicaid work requirement infrastructure while administering the Rural Health Transformation Program. It is doing all of this while operating through the largest federal workforce contraction in decades. Whether the agency can deliver on the full scope of what it has committed to is the binding constraint that touches every other policy question in this series.

Summary: CMS Under Pressure

Sun, 15 Mar 2026 00:00:00 +0000

Every article in the Medicare Policy Analysis Series assumes CMS can execute what it announces. That assumption requires examination. In 2025 and 2026, CMS is simultaneously launching WISeR across six states, running the full annual MA and Part D rulemaking cycle, managing a complete risk adjustment overhaul, standing up ACCESS and BALANCE as new CMMI models, extending AHEAD through 2035, implementing OBBBA’s Medicaid work requirement infrastructure, and administering the Rural Health Transformation Program. It is doing all of this while operating through the largest federal workforce contraction in decades. Whether the agency can deliver on the full scope of what it has committed to is the binding constraint that touches every other policy question in this series.

Telehealth at the Crossroads

Sun, 15 Mar 2026 00:00:00 +0000

Medicare telehealth went from a marginal, geography-bound benefit covering a narrow list of services to a program processing tens of millions of visits annually between March 2020 and the end of the COVID public health emergency. The expansion happened through emergency waivers, not permanent legislation. Every expansion since then has been temporary, attached to continuing resolutions and year-end packages, subject to lapse whenever Congress fails to act. The flexibilities now run through December 31, 2027, secured in the Consolidated Appropriations Act of 2026 after a 43-day government shutdown that interrupted telehealth coverage entirely in late 2025. Whether any of this becomes permanent law, what permanence would require, and who bears the risk of the next lapse is what this article examines.

Summary: Telehealth at the Crossroads

Sun, 15 Mar 2026 00:00:00 +0000

Medicare telehealth went from a marginal, geography-bound benefit to a program processing tens of millions of visits annually between March 2020 and the end of the COVID public health emergency. None of that expansion was permanent. Every extension since then has been temporary, attached to continuing resolutions and year-end packages. The current flexibilities run through December 31, 2027, secured in the Consolidated Appropriations Act of 2026 after a 43-day government shutdown that interrupted telehealth coverage entirely for 43 days in fall 2025. Whether any of this becomes permanent law, what permanence would require, and who bears the risk of the next lapse is the question this article addresses.