In this update:
- Legislative Update
- Update on Government Funding Negotiations
- Federal Agencies
- ACIP Changes Vaccine Recommendations
- CMS Finalizes Rule on MA Provider Directory Integration
- FDA Requires Tylenol Re-Labeling; Authorizes Treatment for Children with ASD
- GAO Publishes Report on Urban Hospital Closures
- GAO Publishes Report on Physician Consolidation
- CMS Issues Additional Guidance on De Minimus Ranges and QHP Timeline Changes
- Other Updates
- Commonwealth Fund Publishes Report on Work Requirements and Hospital Margins
- MACPAC Holds September 2025 Meeting
- Northeast Public Health Collaborative Formed
- CBO Estimates Effects of Permanently Enhanced Premium Tax Credits
- New York State Update
- DOH Proposes ABA Reimbursement Cuts, Adds Fertility Preservation Services
Legislative Update
Update on Government Funding Negotiations
Congress was in recess this week amidst a looming government shutdown. Republicans continue to push for a “clean” seven-week continuing resolution (CR), while Democratic leadership continues to push for negotiations around key health care issues, including an extension of enhanced Affordable Care Act premium subsidies, and a rollback of Medicaid cuts included in the One Big Beautiful Bill Act. President Trump canceled a scheduled meeting with Democratic leaders earlier in the week, calling their policy requests “unserious and ridiculous”. Instead, on September 24th, the Office of Management and Budget sent a memo to federal agencies, instructing them to prepare reductions-in-force (RIF) plans for mass firings in the event of a shutdown. The memo directs agencies to identify programs with no alternative funding source, and to draft RIF plans that permanently eliminate jobs inconsistent with President Trump’s policies. Government funding expires on September 30th.
Federal Agencies
ACIP Changes Vaccine Recommendations
On September 19th, the CDC’s Advisory Committee on Immunization Practices (ACIP) conducted a two-day session to discuss Covid-19 vaccines and the pediatric vaccine schedule. The new, 12-member panel voted to restrict a combination measles, mumps, rubella, and varicella vaccine to children over age 4, while tabling a vote on delaying hepatitis B shots currently given to infants at birth. The Committee backed away from a recommendation that individuals seeking a Covid-19 vaccine get a prescription from a doctor, instead supporting “shared decision making” which calls for patients over six months of age to speak with their doctor about the risks and benefits of the shot, a significantly narrower recommendation than in previous years.
Prior to ACIP’s meeting and subsequent recommendations, America’s Health Insurance Plans announced that their members would continue coverage of immunizations according to recommendations in effect on September 1, 2025.
The press release announcing ACIP’s recommendations is here.
CMS Finalizes Rule on MA Provider Directory Integration
On September 18th, CMS published a final rule on a Biden-era proposal requiring Medicare Advantage (MA) provider directories to be integrated into the Medicare Plan Finder (MPF). This new functionality will enable people with Medicare and their caregivers to determine if a specific provider is in-network for a specific MA plan, enhancing transparency and plan comparability for beneficiaries. The final rule also requires MA organizations to attest to the accuracy of the provider directory data that they will be providing to CMS to populate online. CMS will soon issue an operational guide to direct MA plans on how to meet technical requirements. The data integration will be complete and available for beneficiary use by CY 2027 open enrollment.
The final rule is here, and the summary memo is here.
FDA Requires Tylenol Re-Labeling; Authorizes Treatment for Children with ASD
On September 22nd, President Trump and HHS Secretary Kennedy announced several initiatives to “confront the nation’s autism spectrum disorder (ASD) epidemic.” First, the FDA will authorize leucovorin for cerebral folate deficiency, which may lead to improvements in speech-related deficits for a subset of children with ASD. Concurrently, the NIH will launch trials and new research “into the impact of leucovorin including safety studies.” In addition, the FDA will pursue a safety label change for acetaminophen (Tylenol) and similar products warning consumers of a potential association between use during pregnancy and adverse neurodevelopmental outcomes. The FDA will notify physicians of this change in policy, and launch a nationwide “public service campaign to inform families and protect public health.” Lastly, NIH announced funding for 13 projects through the Autism Data Science Initiative, which “integrates large-scale biological, clinical, and behavioral data with an exposomics approach that examines environmental, nutritional, medical, and social factors alongside genetics.”
In response to the announcement, the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatricians (AAP), the Society for Maternal Fetal Medicine (SMFM), and the Autism Society of American (ASA) all strongly objected to the statements and policy decisions made by President Trump and Secretary Kennedy, and reaffirmed the safety of acetaminophen use during pregnancy.
The HHS press release is available here. The ACOG statement is available here.
GAO Publishes Report on Urban Hospital Closures
On September 24th, GAO published a new report on urban hospital closures and how these closures affect communities served. In this report, GAO researchers compiled data from a nongeneralizable sample of five hospitals in urban areas that closed in 2022 and 2023. These five selected urban hospitals reflect variation in geographic region and ownership type (for-profit vs. nonprofit), and some continued to provide outpatient services post-closure. All hospitals in the study experienced financial losses or declining profits in the five years leading up to closure, and all had aging physical infrastructures that were outdated and/or difficult to maintain. Four of five hospitals also had low or declining patient volumes prior to closure. Communities affected by these closures reported challenges to accessing care, whether due to geographic distance, wait times, or insurance coverage.
The full report is available here.
GAO Publishes Report on Physician Consolidation
On September 22nd, GAO published a new report on the extent and effects of physician consolidation. The report concludes that the share of physicians in practices owned by other entities has increased significantly over recent years. The percentage of physicians employed by or affiliated with a hospital system increased from less than 30% in 2012 to at least 47% in 2024. GAO notes that such physician consolidation with hospital systems “can lead to increased spending and prices” with “no changes in the quality of care.” The report provides less information on physician consolidation under private equity models, but suggests that price increases also occur in this model.
The full report is available here.
CMS Issues Additional Guidance on De Minimis Ranges in Response to Court Motion
On September 18th, a federal appeals court denied a motion by the Trump administration to proceed with the expanded actuarial value (AV) de minimis ranges included in the 2026 Marketplace Integrity final rule. The expanded de minimis range policy was one of seven provisions in the final rule that a district court judge paused as that Court considered a lawsuit brought earlier this year. In response, also on September 18th, CMS issued yet another revision to the 2026 Quality Health Plan (QHP) data submission and certification timeline. As announced in its September 5th memo, CMS will offer issuers a limited data change window from September 30th to October 2nd to update rate and form filings and revise QHP certification applications to reflect the allowable AV de minimis ranges (that were in effect prior to the Marketplace Integrity final rule). CMS is also offering a new, additional opportunity for issuers to withdraw plans, from September 16th to 25th. Several other dates in the timeline have been revised.
The appeals court denial is available here, CMS’ September 18th guidance is available here, and the previous guidance from CMS, issued September 5th, is available here.
Other Updates
Commonwealth Fund Publishes Report on Work Requirements and Hospital Margins
On September 19th, the Commonwealth Fund published a new report analyzing the projected impact of new federal work requirement policies for Medicaid expansion populations on acute care hospitals. The report analyzes financial and operational data from hospitals in Arkansas and New Hampshire – two states that previously implemented work requirement policies – and extrapolates findings to estimate the impact on hospitals in all 40 Medicaid expansion states, plus the District of Columbia. The Commonwealth Fund estimates a reduction in hospital operating margins by an average of 11.7% to 13.3% in Medicaid expansion states once federal work requirement policies are in effect. Safety-net hospitals are likely to experience an even starker impact, with operating margins falling an average of 25.9% to 29.6%. Finally, the report discusses the ripple effect that significant drops in hospital operating margin is likely to have on communities and patients, regardless of insurance type, including increased uncompensated care costs, reduced staff, longer wait times, or eliminated services.
The Commonwealth Fund report can be found here.
MACPAC Holds September 2025 Meeting
On September 18th and 19th, the Medicaid and CHIP Payment and Advisory Commission (MACPAC) held its monthly public meeting. Commissioners discussed preparations for state implementation of the One Big Beautiful Bill Act (OBBBA), including accessibility and efficiency of Medicaid and CHIP programs, potential interactions with state waivers, FMAP changes and implications for sustainability, and external market pressures (e.g., drug costs). In a related presentation, the commissioners discussed anticipated challenges to implementing and administering new state work requirements, including evaluation and measurement, eligibility clarifications, staffing, and information technology requirements. Other topics discussed included new Home and Community Based Services wage data recommendations, the need for more sophisticated data collection and analyses of behavioral health services, improved managed care for youth in foster care, improved coordination of services for justice-involved youth, and increased clarity and planning for Medicare-Medicaid transitions. MACPAC’s next meeting is scheduled for October 30th and 31st.
The slides presented at MACPAC’s September meeting can be found here.
Northeast Public Health Collaborative Formed
On September 18th, nine states announced the creation of the Northeast Public Health Collaborative, a coalition to issue vaccine recommendations and coordinate public health efforts across member states. The Northeast Collaborative includes most states in Maine, Massachusetts, Rhode Island, Connecticut, New York (including New York City, the largest municipal health department in the nation), New Jersey, Pennsylvania, Delaware, and Maryland. Vermont separately announced it had joined. The Collaborative’s first set of recommendations is related to the Covid-19 vaccine, and mirror the guidance of the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians.
The Collaborative’s specific Covid-19 guidance is available here.
CBO Estimates Deficit, Premium, and Coverage Effects of Permanent Enhanced Premium Tax Credits
On September 18th, the Congressional Budget Office (CBO) issued an estimate on the effects of several policy changes related to Affordable Care Act (ACA) premium tax credits and marketplace governance, at the request of several Democratic Senators. In general, all three policy changes would increase both federal deficits and the number of people with insurance. In particular:
- Permanently extending the enhanced ACA premium tax credits would increase deficits by $349.8 billion over the 2026-2035 budget window, increase the number of people with health insurance by 3.6 million in 2030 and 3.8 million in 2035, and lower gross premiums for benchmark Marketplace plans by 7.6% in each year from 2026-2035. Notably, CBO estimates that if the permanent extension is enacted on September 30th, premiums for 2026 plans would be just 2.4% lower due to the probability that 2026 premiums would not be adjusted given the open enrollment timeline.
- Nullifying the final 2026 Marketplace Integrity rule would increase deficits by $40.3 billion over the ten-year budget window and increase the number of people with health insurance by 200,000 in 2030 and 300,000 in 2035.
- Repealing sections of the One Big Beautiful Bill Act (OBBBA) related to the health insurance marketplaces would increase deficits by $271.9 billion over the ten-year budget window and increase the number of people with health insurance by 2.8 million in 2030 and 2.9 million in 2035.
The CBO estimate is available here.
New York State Update
DOH Proposes ABA Reimbursement Cuts, Adds Fertility Preservation Services
On September 24th, the New York State (NYS) Department of Health (DOH) issued public notices in the State Register announcing plans to implement several 2025-26 Enacted Budget initiatives via State Plan Amendments.
The first initiative proposes a reduction in Medicaid reimbursement for Applied Behavior Analysis (ABA) services provided by unlicensed personnel under the direction of a Licensed Behavior Analyst (LBA). Currently, the Medicaid program reimburses for ABA services provided by unlicensed personnel at the same rate as LBAs. DOH notes that the reduction both aligns NYS Medicaid with other state Medicaid programs and ensures that ABA providers are compensated appropriately based on their training and experience. The State anticipates Medicaid savings of $1.3 million in State Fiscal Year (SFY) 2025-26 as a result of this initiative.
The second initiative proposes Medicaid coverage of fertility preservation services for individuals whose infertility is directly or indirectly caused by medical treatment (e.g., surgery, chemotherapy, sickle cell treatment). Such services include medically necessary collection, freezing, preservation, and storage of oocytes or sperm and prescription drugs. The State anticipates an increase of $4.6 million in Medicaid expenditures for SFY 2025-26 attributable to this initiative.
Additional information is available in the State Register here. Public comment may be submitted to spa-inquiries@health.ny.gov.