V-BID Update: Patient Costs, Drug Access, and Coverage Changes

In this Issue:

• CMS Tests New Medicare Coverage Model for Weight Loss Drugs
• Declining Part D Plan Availability May Affect Beneficiaries
• Cervical Cancer Guideline Recommends Full Coverage of Follow-up Services
• Medical Debt Burdens Differ by Race and Affect Health
• Employer-Sponsored Insurance Shows Persistent Cost Differences by Size
• Prison Copayments Are Linked to Worse Health Outcomes
• Out-of-Pocket Costs for Multiple Sclerosis Care Rise Sharply Over Time
• Zero-Dollar Copays Linked to Lower Health Spending in Diabetes
• Healthcare Remains Top Priority for Americans
• Record Share of Americans See U.S. Health System in Crisis
• Workshop Report Identifies Key Drivers of Patient Cost Exposure
• 2026 V-BID Summit Save-the-Date

CMS Tests New Medicare Coverage Model for Weight Loss Drugs

CMS announced the voluntary BALANCE Model to expand access to GLP-1 weight-loss drugs under Medicare Part D and Medicaid. The model allows CMS to negotiate net prices, set standardized coverage terms, and lower OOP costs, with Medicaid participation starting in 2026 and Part D in 2027. CMS will evaluate effects on access, spending, and health outcomes as details are finalized.

Declining Part D Plan Availability May Affect Beneficiaries

A Commonwealth Fund analysis finds that Medicare Part D plan availability has declined in many areas, reducing choice and potentially increasing premiums for beneficiaries. Rural counties have seen the largest decreases in stand-alone plan options, while some urban areas still maintain more competitive offerings. Fewer plan choices may limit beneficiaries’ ability to find coverage that best fits their medication needs and budgets.

Cervical Cancer Guideline Recommends Full Coverage of Follow-up Services

New cervical cancer screening guidelines recommend that all follow-up services after a positive initial test be treated as part of preventive care and covered with no out-of-pocket cost for insured patients, beginning in 2027. The update defines diagnostic workups as part of the cancer prevention continuum rather than separate services. Coverage of patient navigation services without cost-sharing began January 1, 2026. These changes aim to reduce financial barriers that can delay completion of recommended follow-up care.

Medical Debt Burdens Differ by Race and Affect Health

A Health Affairs brief finds that Black and Hispanic adults are more likely than White adults to carry medical debt and report negative health impacts from that debt. Medical debt is linked to delayed care, worse self-reported health, and increased financial hardship, with racial disparities persisting even after adjusting for income. The brief suggests targeted debt relief and policy strategies could help reduce these inequities and improve health outcomes.

Employer-Sponsored Insurance Shows Persistent Cost Differences by Size

New data from AHRQ’s Medical Expenditure Panel Survey show continued differences in insurance costs between small and large private employers. In 2024, deductibles at small firms were about 25% higher than at large firms, with average family deductibles of $5,087 compared with $3,920. Single-plan deductibles also remained higher at small firms, averaging $2,474 versus $2,007 at large firms. The findings highlight ongoing disparities in cost exposure for workers based on employer size.

Prison Copayments Are Linked to Worse Health Outcomes

A new study finds that health care copayments in prisons are associated with higher COVID-19 transmission and reduced access to care. Facilities that eliminated or never charged copayments saw lower transmission rates, suggesting cost-sharing discouraged timely care seeking. The findings highlight how even modest patient costs can impede access in high-risk settings.

Out-of-Pocket Costs for Multiple Sclerosis Care Rise Sharply Over Time

A new analysis of commercially insured adults and children with multiple sclerosis finds that annual out-of-pocket costs more than doubled between 2002 and 2021, rising from about $1,800 to over $4,000 per patient. Disease-modifying therapies drove most of this increase, accounting for more than 50% of out-of-pocket spending by 2021, compared with about 13% in 2002. Total health care costs also tripled over the study period, reaching nearly $74,000 per patient, largely due to escalating spending on newer MS treatments.

Zero-Dollar Copays Linked to Lower Health Spending in Diabetes

A study finds that offering a zero-dollar copay pharmacy benefit for members with type 2 diabetes was associated with lower overall healthcare expenditures among Blue Cross Blue Shield of Louisiana enrollees. Members with the no-copay benefit filled more prescriptions and had better medication adherence compared with those facing standard cost-sharing. The analysis suggests that eliminating out-of-pocket drug costs for chronic conditions can reduce total spending, while improving treatment uptake.

Healthcare Remains Top Priority for Americans

A recent poll finds that a majority of U.S. adults continue to rank healthcare as a leading issue facing the country, with concerns centered on cost, access, and insurance coverage. Rising prescription drug prices and affordability of care remain major drivers of public concern. The results underscore sustained public pressure on policymakers to address healthcare affordability and coverage gaps.

Record Share of Americans See U.S. Health System in Crisis

Nearly 1 in 4 U.S. adults now say the health care system is in a “state of crisis,” with 29% citing high costs as the most urgent problem facing the nation, according to a recent Gallup poll. Concern about cost and access has risen across party lines, with large majorities of both Democrats and Republicans expressing serious misgivings. Many respondents say they—or people they know—are delaying or skipping needed care because of expense, underlining widespread affordability challenges.

Workshop Report Identifies Key Drivers of Patient Cost Exposure

A new Value Research workshop report examines factors contributing to high patient cost exposure, highlighting how benefit design, price transparency gaps, and utilization management practices interact to increase out-of-pocket spending. The report identifies evidence gaps and proposes areas for future research, including standardized cost measurement and value-aligned benefit designs. Stakeholders emphasize that more consistent data and patient-centered metrics are needed to guide policy and plan design improvements.

Missed an Issue of Our Newsletter?

You can always find previous editions of our weekly newsletters on our website here.