In case the federal government moves to ban 'silver-loading,' the plaintiffs are trying to keep their legal options open.
Eighteen states suing the Trump administration over its decision last fall to halt cost-sharing reduction (CSR) payments under the Affordable Care Act asked a federal judge Monday to put their proceedings on hold.
Despite acknowledging the success of a workaround known as "silver-loading"—which allows insurers to offset the cost of the unfunded CSR subsidies by raising premium prices for middle-tier plans on the ACA exchanges—the plaintiffs argued that the judge should keep their legal options open, in case the federal government moves to prohibit the silver-loading stopgap.
"In a situation such as this, the States would normally move to dismiss the present action, without prejudice to their ability to file a new complaint when the circumstances changed," the plaintiffs wrote in their filing. "Here, however, the States respectfully suggest that the better course would be for the Court to stay these proceedings but to retain jurisdiction over them, at least for the time being."
The plaintiffs, led by California Attorney General Xavier Becerra—who pledged last month to defend the ACA against a separate challenge in Texas after the federal government declined to defend the constitutionality of key provisions in the Obama-era law—argue that certain Trump administration officials have already indicated their desire to chip away further at the ACA by blocking silver-loading.
"There is accordingly every reason to be wary of the possibility of sudden, unilateral, and irresponsible federal action that could call for turning swiftly back to the issues presented by this case," the plaintiffs wrote.
Past statements: Centers for Medicare & Medicaid Services Administrator Seems Verma said in March that she is "very concerned" by silver-loading, the plaintiffs wrote, citing media reports. In April, Verma said the Trump administration is looking into prohibiting statesfrom using the workaround. Health and Human Services Secretary Alex Azar told Congress that the administration would not block silver-loading for 2019, though he did not offer that assurance for 2020 and beyond, the plaintiffs noted.
Workaround has worked: Silver-loading has "largely protected subsidized consumers from the harm inflicted by the decision to end CSRs, and provided some stability to help ensure a functioning insurance market," the plaintiffs wrote, citing a Health Affairs article. The workaround has also lowered premiums for low-income consumers, as the National Academy for State Health Policy reported.
But premiums are on the rise: Citing analysis by the Kaiser Family Foundation, the plaintiffs said 2019 premiums nationwide are projected to increase 7-36% "due to the uncertainty in the individual market driven by, among other things, the end of CSRs." That has hit unsubsidized consumers especially hard, the plaintiffs argued.
Rising premiums as impetus: The government has cited rising premiums as a rationale for expanded access to non-ACA-compliantshort-term limited-duration and association health plans.
If the government were to block silver-loading, it would further destabilize the individual market and push premiums higher for all ACA exchange plan tiers, the plaintiffs argued.
The defendants in this case indicated opposition to the states' request for a stay, preferring instead that the matter be dismissed without prejudice, according to the filing.
The agency's proposed changes to the Quality Payment Program drew a mixed response from industry stakeholders.
Major changes are in store for the Merit-based Inventive Payment System (MIPS) in 2019, as the Trump administration pushes to reduce the recordkeeping burden shouldered by clinicians.
In a slate of proposals released late last week, the Centers for Medicare & Medicaid Services outlined 10 new quality measures it would like to add to the MIPS program, plus dozens it wants to remove. The measures on the chopping block are process-based items clinicians have identified as "low-value or low-priority," CMS said.
The agency also proposed changes to the MIPS "promoting interoperability" performance category. The changes are designed to improve interoperability of electronic health record (EHR) data, give patients easier access to their own health data, and align the performance category with a similar proposal for hospitals.
These proposed changes to the Quality Payment Program are good news, said Gerald Maccioli, MD, MBA, FCCM, chief quality officer for Envision Healthcare.
"As a country, we continue on a positive and productive pathway to figuring out how to use quality measures to markedly improve the health of our communities, and with the proposed changes CMS is moving in the right direction," Maccioli said in a statement.
"The streamlined measures signify that CMS is listening to clinicians and acknowledging the need to lessen their administrative burden by focusing on the measures that will make the most tangible impact on care delivery and patient outcomes," he added. "Clinicians are the voice from the front lines of patient care so it’s imperative that we involve them in quality improvement initiatives."
Not everyone, however, was pleased with the proposals.
Jerry Penso, MD, MBA, president and CEO of the American Medical Group Association (AMGA) said CMS is continuing to propose policies that "do not further the program's intent and potential." Penso took particular exception to the fact that CMS opted to keep a low-volume threshold that AMGA considers too high.
The group had earlier this month applauded a letter from lawmakers urging CMS to lower the MIPS exclusion threshold to open the program up to more clinicians. About 60% of otherwise-eligible clinicians are excluded from the program due to the threshold, preventing them from earning the payment adjustment authorized by the Medicare Access and CHIP Reauthorization Act (MACRA), AMGA said.
Even though some Medicare Advantage plans look a lot like Advanced Alternative Payment Models (APMs), physicians who participate in these innovative MA plans are still subject to MIPS, CMS said. This MAQI demonstration will test whether waiving the MIPS requirement could increase participation in these MA plans and whether it improves patient care.
Blair Childs, senior vice president of public affairs for Premier, commended the move as a positive sign that CMS is looking to loosen some of the regulations that would otherwise dampen APM participation in 2019 and 2020.
"Testing MA participation in APMs through the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration is a useful first step, and we support a qualification threshold that would be comparable to other advanced APMs," Childs said in a statement. "We look forward to providing comments to help shape the demonstration."
A price transparency RFI released by the agency this week asks for input on how CMS might develop consumer-friendly policy.
In a request for information announced Thursday, the Centers for Medicare & Medicaid Services asked whether providers and suppliers should be required to tell patients, in advance, how much a given healthcare service will cost out-of-pocket.
If the agency were to move forward with a price transparency requirement on physician practices, it could prove controversial. Many doctors say they themselves lack the training they would needto have effective conversations about how much the healthcare services they provide will ultimately cost patients.
But CMS has repeatedly indicated that it aims to get more pricing information to consumers one way or another.
"We are concerned that challenges continue to exist for patients due to insufficient price transparency," the agency wrote in its RFI, which is included in proposed revisions to the Physician Fee Schedule, Quality Payment Program, and other policies for 2019.
Some patients, for example, have received surprise bills for out-of-network doctors who provided services at in-network facilities, CMS said.
"We also are concerned that, for providers and suppliers that maintain a list of standard charges, the charge data may not be helpful to patients for determining what they are likely to pay for a particular service or facility encounter," the agency added.
Earlier this year, as part of the proposed Inpatient Prospective Payment Systems (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) for 2019, CMS said it would begin requiring that hospitals not only make a list of their standard charges public but that it do so online in a machine-readable format with annual updates.
In order to determine what additional actions may be appropriate to connect consumers with accessible price information, the CMS price transparency RFI includes a variety of questions, including the following:
How should the phrase "standard charges" be defined in various provider and supplier settings?
Which information types would be most useful to beneficiaries, and how can providers and suppliers empower consumers to engage in price-conscious decision-making?
Should providers and suppliers have to tell patients how high their out-of-pocket costs are expected to be before providing a service?
The full list of questions, with details on how to submit a comment are available in the Federal Register. Comments are due September 10 by 5 p.m.
The changes were proposed Thursday with updates to the Physician Fee Schedule and Quality Payment Program for 2019.
For more than two decades, physicians have billed Medicare by thoroughly documenting each patient visit with a set of evaluation and management codes, which many have argued are overly burdensome.
Next year, however, that E/M documentation process will change dramatically, if the Centers for Medicare & Medicaid Services gets its way. The agency announced Thursday that it proposes to simplify the documentation requirements for such office visits, affording physicians greater flexibility.
"Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care. This Administration has listened and is taking action," said CMS Administrator Seema Verma in a statement Thursday.
"The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on, by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need," Verma added.
The proposal calls for E/M payment to be simplified in several ways, CMS said:
Rather than continuing to comply with documentation guidelines from the 1990s, practitioners would be able to choose to document E/M visits based on time spent with the patient or on their own medical decision-making.
Allowing time to be the primary factor in determining visit level, without regard to how much of that time was spent counseling or coordinating care, would expand the number of options available to physicians.
Rather than having to re-document information from past visits, practitioners would have more options to simply review and update existing documentation.
Physicians would further be allowed to simply review and verify certain medical records that staff members or the patient entered.
The proposal would transform the current five-tier E/M system into one with blended payment rates for office and outpatient visits billed at the second through fifth levels.
Health and Human Services Secretary Alex Azar said Thursday's proposals are part of "a historic regulatory rollback" that will help physicians prioritize the needs of their patients, and the moves drew praise from some industry groups.
"We support efforts to reduce these burdens on clinicians, whether they were created by paper or electronic processes, and to give physicians more time to care for patients," said Liz Johnson, MS, RN-BC, chief information officer for acute hospitals and applied clinical informatics at Tenet Healthcare.
Expanded Telehealth Payments
The CMS proposals also call for doctors to be paid for the time they spend communicating with patients over the phone or via other telecommunication channels, regardless of whether an office visit or other service is rendered. The proposals even call for physicians to be paid for the time they spend reviewing patient images or video.
Johnson, who chairs the public policy steering committee for the College of Healthcare Information Management Executives (CHIME), said CIOs like her applaud the expanded reimbursement for telehealth, which is something they have prioritized for awhile now.
American Hospital Association Executive Vice President Tom Nickels similarly praised CMS for taking steps to expand payments for telehealth and other virtual connections.
Nickels also expressed disappointment in a site-neutral policy that took effect this year. The policy—which Nickels called "short-sighted" and which CMS said is designed to encourage "fairer competition between hospitals and physician practices"—causes newer off-campus facilities to be paid at 40% of the hospital Outpatient Prospective Payment System (OPPS) rates for outpatient services.
"These 'site-neutral' policies ignore the need for hospitals to modernize existing facilities so that they can provide the most up-to-date, high-quality services to their patients and communities," Nickels said.
The proposed change for 2019 would reduce the wholesale acquisition cost add-on from 6% to 3%, decreasing the amount of money Medicare and beneficiaries pay for in-office drugs.
The Centers for Medicare & Medicaid Services announced a series of proposed changes Thursday to Medicare's physician fee schedule for 2019 promising, among other things, to advance the Trump administration's commitment to lowering prescription drug prices.
Included in the proposal is a significant reduction in the amount Medicare pays physicians for new prescription drugs. Rather than calculating reimbursement by adding 6% to the wholesale acquisition cost (WAC) for drugs and biologics, CMS would pay physicians WAC plus 3% effective January 1.
The proposal would not affect payments that are required by law to be calculated at the volume-weighted average sales price (ASP) plus 6%, according to the proposed rule.
Beyond reducing Medicare's fee-for-service expenses, the reduction would also decrease copayments for Medicare Part B beneficiaries, according to the proposal.
"The proposed approach would help Medicare beneficiaries afford to pay for new drugs by reducing out of pocket expenses and would help counteract the effects of increasing launch prices for newly approved drugs and biologicals," the proposal states.
Asked about the impact the cut would have on providers, CMS Administrator Seema Verma said during a press call Thursday that the agency will listen to feedback as the rulemaking process moves forward.
"This is a proposed rule, so we are going to continue to work with providers and stakeholders and continue to have dialogue around their response to the rule," Verma said.
Recommended by MedPAC: In support of its proposal, CMS noted that the Medicare Payment Advisory Commission recommended the reduction in its June 2017 report to Congress.
Expected to curtail spending: Medicare Part B drug spending increased from $17.6 billion in 2011 to $28.0 billion in 2016, while per-capita spending increased 54%, according to CMS data. "These increases affect the spending by Medicare and beneficiary out-of-pocket costs," the proposal states. "In the context of these concerns, we believe that implementation of these proposals will improve Medicare payment rates by better aligning payments with drug acquisition costs, especially for the growing number of drugs with high annual spending and high launch prices where single doses can cost tens or even hundreds of thousands of dollars."
Why 3%? "Although other approaches for modifying the add-on amount, such as a flat fee, or percentages that vary with the cost of a drug, are possible, we are proposing a fixed percentage in order to be consistent with other provisions [of the law] which specify fixed add-on percentages" of 6% or 3%, the proposed rule states. "A fixed percentage is also administratively simple to implement and administer, is predictable, and is easy for manufacturers, providers and the public to understand."
AHA uneasy: Tom Nickels, executive vice president of the American Hospital Association, released a statement expressing unease over the reduction in payment for certain new drugs: "[W]e believe CMS should instead address the skyrocketing list prices of drugs directly with pharmaceutical manufacturers," he said.
Verma made a point during Thursday's call to mention that more drug-pricing related changes are on their way.
"When it comes to lower drug pricing, you're going to see many initiatives that come out from the administration," she said. "This is certainly not only one thing that we will be doing. With upcoming announcements, I think you'll be able to see some of the things we're doing on this."
Public comments on the proposed physician fee schedule will be accepted through September 10.
Editor's note: This story has been updated to include a comment from the American Hospital Association.
Americans without health insurance and those with high out-of-pocket costs are expected to be worst affected.
The cost of certain medical equipment imported from China is expected to rise significantly in the U.S. due to escalating trade tensions between Washington and Beijing.
When the Trump administration announced a 25% planned tariff last month on $50 billion in Chinese goods, healthcare industry stakeholders worried the move could put them in a financial pinch. China responded tit for tat, then the White House escalated this week, proposing a 10% tariff on an additional $200 billion in imports from China.
All of this means that the cost of medical equipment in the U.S. will increase by about $400 million nationwide, assuming that import levels hold steady, according to research released Thursday by the American Action Forum, which describes itself as a "center-right policy institute."
The AAF research identified 55 products on the updated tariff lists, including medical imaging equipment and surgical instruments, which account for nearly $1.8 billion annually in imports subject to the tariff.
"Both medical practitioners and consumers of medical services can expect to shoulder the burden of these costs," wrote AAF Director of Immigration and Trade Policy Jacqueline Varas and AAF Deputy Director of Health Care Policy Tara O'Neill Hayes.
Providers will likely pass the estimated $400 million increase along to their patients by raising prices, but the impact on patients will differ depending upon the terms of their health insurance coverage, Varas and Hayes noted.
"These higher prices will hit the uninsured and those with substantial out-of-pocket liabilities hardest," they wrote.
Healthcare leaders overwhelmingly believe physicians aren't trained to have informed conversations about how much the care they provide will cost their patients. That could impede value-based care.
An overwhelming majority of healthcare leaders who responded to a recent survey said they believe physicians are ill-equipped to discuss healthcare costs effectively.
About 86% of the 571 clinicians, clinical leaders, and executives who responded said physicians lack the training they would need to discuss the cost considerations affecting their patients, according to data released Tuesday by University of Utah Health in partnership with NEJM Catalyst.
Another 8% said they neither agreed nor disagreed with the prompt.
Robert Glasgow, MD, chief value officer for University of Utah Health's surgery department in Salt Lake City, said it's easy for physicians to feel powerless to influence prices set by insurers or drug-makers. But that doesn't mean doctors should resign themselves to shrug whenever asked about the price tags attached to each treatment.
"We need to train physicians to give patients enough cost data," Glasgow said in the survey report. "That’s the starting block of high-value care."
That being said, doctors shouldn't be pressured to come up with "an itemized bill," nor should they let their interactions with patients be reduced to mere business transactions, he added.
This idea that providers should be enabling consumers to make price-conscious healthcare decisions is, of course, not new. Ohio lawmakers even passed a requirement for providers to give patients a "good faith" estimate of how much non-emergency services would cost. A judge barred the state from implementing the law, however, amid a challenge by the Ohio Hospital Association and others, as The Columbus Dispatch reported.
"Doctors and hospitals are going to be getting more and more questions around cost and quality, and in the early stages of consumer-driven healthcare they often looked at the patient and said they no idea what this service would cost or how to measure quality," said Alegeus senior vice president of consumerism and strategy John Young at the time.
"That is becoming less common today as doctors and hospitals develop better mechanisms for answering those questions, which in some cases means having a specific department or person to refer the patient to," Young added.
What's Driving Costs? Docs Blame Pharma
About 72% of the 571 people who responded to the survey sponsored by University of Utah Health. When asked which stakeholders are to blame for high healthcare costs, the respondents pointed their fingers most vigorously at the pharmaceutical industry—but insurers and providers were not that far behind.
A majority of respondents listed the following stakeholder categories as having a "strong impact" on the cost of healthcare:
Several other stakeholder categories ranked lower in the list of factors having a "strong impact" on healthcare costs: individual clinicians (28%), employers (26%), and patients (23%).
While officials contend the program has not been a cost-effective use of federal funds, proponents of the ACA see yet another attempt to undermine implementation of the Obama-era law.
For the second time in two years, the Trump administration has dramatically slashed funding for a grant program that helps Americans sign up for health insurance under the Affordable Care Act exchanges.
The program, which supports outreach organizations and so-called "navigators" to assist consumers through the enrollment process, had received $63 million for the open enrollment period in fall 2016. But that funding was cut last year to $36 million, and it will drop again this fall to a maximum of $10 million, the Centers for Medicare & Medicaid Services announced Tuesday. That's a reduction of more than 84% in two years.
While the administration says the cuts are motivated by a need to allocate federal resources prudently, Democrats and proponents of the ACA contend that this is yet another attempt by the Trump administration to undermine implementation of the Obama-era law.
"This decision reflects CMS' commitment to put federal dollars for the Federally-facilitated Exchanges to their most cost effective use in order to better support consumers through the enrollment process," CMS Administrator Seema Verma said Tuesday, adding that it's time for the navigator program "to evolve."
Despite spending tens of millions of dollars in 2016 and 2017, navigators have enrolled less than 1% of the beneficiaries who signed up for coverage on the exchanges each year, CMS said. Agents and brokers, however, have assisted with 42% of enrollments for the current plan year, the agency added.
About that evolution: Beyond simply cutting funds, CMS is pushing to overhaul the program's mission. Navigators will now be encouraged to provide consumers with information on non-ACA-compliant plans, such as short-term limited-duration options and association health plans, CMS said. The administration has been criticized for touting these cheaper alternatives as a release valve of sorts for rising premiums in ACA-compliant plans.
Impact on in-person help: "This is a huge cut to navigator programs across the country. It will virtually eliminate face-to-face in-person assistance," Fred Ammons, who oversees the navigator organization Insure Georgia, told The New York Times. "It means less help, much less help, to underserved, hard-to-reach populations, people who live in rural areas or have low literacy or don't speak English as their primary language."
Rounding error? "It's not the most consequential act of sabotage we've seen. But it is among the most revealing," said Huffington Post healthcare reporter Jonathan Cohn in a series of tweets Wednesday about the slashed navigator funding. The program's less-than-$40 million price tag last year is "not even a rounding error" in the context of federal healthcare spending, and the program doesn't exist to maximize overall enrollment numbers, he said: "It's to provide assistance to people who need it."
In its payment notice, CMS also removed the requirements that each exchange have a minimum of two navigators and that navigators maintain a physician presence in the area being serviced.
"Removing these requirements will help to lower operating costs and focus on enrolling consumers as well as enable grantees to engage in digital and online outreach to reach a broader audience," CMS said.
A minimum of $100,000 will be awarded to grantees in each of the 34 federally facilitated exchanges starting this fall.
The company had appeared to weather criticism from the White House when it announced it would backpedal from the July 1 increases.
In a surprising reversal, pharmaceutical giant Pfizer said Tuesday it would back down from planned price hikes for several dozen of its drugs amid heavy criticism from the White House.
After weathering a one-two punch Monday from the president and his Health and Human Services secretary, who took turns publicly lambasting the company, Pfizer appeared to have escaped unscathed, at least in terms of its performance on Wall Street.
The company's stock dipped after President Trump tweeted Monday afternoon that it and other pharma firms "should be ashamed that they have raised drug prices for no reason." But shares rebounded to close the day up slightly, as Bloomberg reported.
Pfizer closed even higher on Tuesday, up another 0.75% to $37.43, suggesting perhaps that Trump's blunt words don't make investors quite as nervous as they did 18 months ago, when the then-president-elect accused drug companies of "getting away with murder"—part of a message that knocked biotechnology shares down about 3%, as Politico reported.
More broadly, this episode could indicate a heightened sense of skepticism in response to the Trump administration's commitment to bring down drug prices.
"Trump can threaten all he wants. He figures such posturing looks good to his base. But his ranting simply reveals an inability to accept that delivering on his promise will be much harder than he realized," Ed Silverman wrote for STAT News.
Even so, Pfizer responded to the criticism after markets closed Tuesday by backpedaling on price hikes that took effect July 1.
The increases affected list prices on 41 products, or about 10% of Pfizer's portfolio of medicines and vaccines, as Reuters reported. But the company said the prices would revert to their pre-July 1 levels "as soon as technically possible" and that they would stay there until the end of the year or Trump implements his initiative to dampen high drug prices, whichever comes first, as The Wall Street Journal reported.
Blueprint defied: Pfizer's price hike came after the White House unveiled its blueprint in May to bring down prescription drug prices, defying Trump's claim that some of the biggest drug makers would be announcing "voluntary massive drops in prices."
After finishing his speech, Azar reiterated the message on Twitter: "Change is coming to drug pricing, whether painful or not for pharmaceutical companies," he wrote, with a link to Trump's earlier tweet.
In a subsequent tweet Tuesday evening, Trump broke the news of Pfizer's reversal: "We applaud Pfizer for this decision and hope other companies do the same."
Azar followed up with a statement of his own, flattering both Pfizer and Trump: "I look forward to working with Pfizer and others who share the President’s concern for patients, and that want to work with us to lower list prices and reduce out of pocket costs," he said.
This latest move by Pfizer is temporary and does not address prior price hikes, which left some industry analysts unimpressed, as CNN Money reported.
Editor's note: This story has been updated throughout to account for developments Tuesday in which Pfizer said it would back down from its July 1 hike. The original headline for this story, "Pfizer Unfazed by Trump's Twitter Lashing," has been updated accordingly.
Beyond the prospect of creating winners and losers in the industry, the uncertainty could threaten to stymie the push toward value-based care models.
As insurers gauge how the freezing of $10.4 billion in risk-adjustment paymentscould impact their financial performance, it's clear that their exposure varies significantly across the industry.
The program, which was designed to be a permanent feature of the Affordable Care Act, transfers money from health plans with lower-risk consumers to plans with higher-risk consumers. It does so to back up the ACA's prohibition on picking and choosing consumers based on their individual risk.
When payments are put on hold, however—as the Centers for Medicare & Medicaid Services announced Saturday would happen for the 2017 benefit year—it creates a list of potential winners and losers. Some companies that had expected hundreds of millions of dollars in risk-adjustment payments fear the funds may fall through, while others that had expected to owe hundreds of millions wonder if they may be off the hook.
This added risk could ultimately dampen the push toward value-based healthcare delivery, says Michael Abrams, MA, co-founder and managing partner of Numerof & Associates.
"No matter how you slice it, injecting more uncertainty into this situation is not good for anyone, regardless of where you stand on value-based models," Abrams tells HealthLeaders Media.
Even if the risk-adjustment payments are merely delayed, not canceled, insurers will likely incur unanticipated expenses related to the delay in cash flow, which could prompt premium hikes, he says.
"Longer-term, I think that the administration's walk-back of risk-adjustment payments penalizes those payers that did, in fact, attempt to enroll participants without bias to health status, and unfortunately it also rewards those payers that for whatever reason decided to play it that much safer and do their best to recruit healthy individuals," Abrams says.
All of this increases the risk payers take by participating in a federally sponsored program, and it makes it more difficult for payers and providers to reach deals with which all parties are comfortable, he adds.
"The reluctance of provider organizations to take on risk has always been I think the principal obstacle here. And the reason that the penetration of value-based programs—even those that have upside-only risk—[has lagged] is that reluctance and the sense that they don't have deep capital reserves, aren't prepared and equipped to handle a significant financial shock like some sort of clawback because they missed their targets," Abrams says.
Insurers: Winners & Losers
In the event that the delay in 2017 risk-adjustments becomes permanent, Kaiser Pemanente stands to gain the most, according to CMS data crunched by Axios' Bob Herman and Harry Stevens. The Oakland, California–based company was expected to owe $928 million for 2017 ACA risk adjustments.
Molina Healthcare came in second, owing $853 million. Centene and Fidelis ranked third, owing $689 million.
On the opposite end of the spectrum, the biggest losers would be Anthem, which expects to receive $522 million; Blue Cross Blue Shield of Florida, which expected to receive $618 million; Health Care Service Corp., which expected to receive $640 million; and Blue Shield of California, which expected a $696 million payout.
Experts seem to agree it's unlikely that CMS will halt the risk-reduction payments altogether, which has critics claiming the Trump administration is simply seeking another means by which to sabotage the law.