Congress Shifts Focus as Health Policy Scrutiny Continues

Capitol Hill has started to quiet down as members of Congress turn their attention toward reelection campaigns. While this means the pace of change in policy is less intense than the beginning of the year, with the enactment of the Consolidated Appropriations Act and its pharmacy benefit manager (PBM) reform provisions, there are still a couple of things managed care professionals should pay attention to this summer. First, Congressional committees have held a series of hearings focused on rising health care costs. Second, there has been legislative movement on niche but potentially significant topics, such as benefit consultant fees and drug patent reform. 

Outside of Washington, DC, Clover Insurance Co prevailed¹ over the US Department of Health & Human Services (HHS) in a legal challenge to the 2026 Star Ratings Clover received from the US Centers for Medicare & Medicaid Services (CMS) in a decision that could have far-reaching consequences for the Star Ratings program.

On May 21, 2026, the House Judiciary Subcommittee on Courts, Intellectual Property, Artificial Intelligence, and the Internet held a hearing² concerning drug patent practices. Much of the discussion focused on so-called “patent thickets,” when brand name drugmakers have multiple overlapping patents on a single drug that extend the life of their monopoly. Policymakers have long supported generic drugs as a key strategy for lowering costs, so it’s no surprise that Congress is looking for ways to get them to market more quickly. Some members and witnesses at the hearing had other opinions, however, expressing concern that changes to drug patent laws could stifle innovation in the pharmaceutical industry. In my opinion, reform is coming. It may not be this year, but the sense on Capitol Hill seems to be that it’s drugmakers’ turn now that PBM reform has passed.

The House Energy & Commerce Committee held a hearing³ on June 10, 2026, regarding price transparency. One of the bills that received significant attention during the hearing was the Patients Deserve Price Tags Act (H.R. 5582, S. 2355)^4,5. This is a broad bill that would impose additional transparency and reporting requirements on actors throughout the health care supply chain, including hospitals and managed care organizations. The role of private equity in hospital consolidation and issue of increasing costs were frequently discussed throughout the hearing. Hospital reform has been politically challenging for decades, so I’m not ready to say that it’s now imminent. But the high level of scrutiny from policymakers is notable and may pressure hospitals into adopting new practices, similar to the changes PBMs made to prepare for long-anticipated reform.  

Turning toward legislation, House committees recently advanced two bills worth monitoring: the Main Street Pharmacy Access Act (H.R. 3164, formerly the Ensuring Community Access to Pharmacist Services Act)⁶ and the PBM Kickback Prohibition Act (H.R. 7895)⁷.

Main Street was favorably reported out of the Ways & Means Committee on May 21. The bill would authorize Medicare Part B reimbursement for certain test and treat services provided by pharmacists related to COVID-19, flu, strep throat, and respiratory syncytial virus if those services are within the scope-of-practice regulations established by state governments. There’s strong—and growing—bipartisan support for this bill. Given the influence of Medicare coverage on commercial benefits, enactment of Main Street may lead to more widespread reimbursement for these services across all managed care lines of business. While the Energy & Commerce Committee still needs to vote on the bill, it looks like it has a good shot of crossing the finish line this year, especially as high priority health vehicles move forward.

The second bill, the PBM Kickback Prohibition Act, was marked up by the Education & Workforce Committee—also on May 21. The name of the bill is a little confusing—it doesn’t address PBM income. Rather, it seeks to prevent PBMs from compensating benefit consultants and brokers for referring clients to them or for providing access to proposal or contracting processes; an exception is made for payment in exchange for bona fide services. Put another way, it would stop brokers and consultants from charging for access. The bill’s framing suggests that PBMs impose these arrangements, but really these arrangements are driven by the brokers, who are not paid directly by health plans or employers. Brokers collect their compensation from the PBMs, who make those payments on behalf of their sponsor clients. Should this bill pass, sponsors would be responsible for making payments to brokers, meaning they would have a new line item in their expenses. That may be a tough pill to swallow.

Clover v HHS

On May 27, 2026, a federal district court in Georgia ruled that 20 of the 45 measures CMS used in issuing its Star Ratings for Clover were impermissible under federal law. Ten of the measures were invalidated on the basis that they used quality measures other than those listed in the Star Ratings statute. The other 10 were invalidated due to the court’s finding that CMS had failed to provide adequate notice-and-comment opportunity before implementing them. 

Clover’s original 2026 Star Ratings fell short of the 4-star threshold to qualify for higher reimbursement rates. Following the ruling, CMS issued new ratings that entitled Clover to the enhanced payments. While the court’s decision is limited to Clover, it will certainly energize other plans seeking to challenge their own ratings. HHS could appeal this decision, leading to the restoration of those metrics if successful. But if the decision stands, it raises serious questions about the future of Star Ratings. Thus far, Congress has not expressed much interest in modifying the law, but that could certainly change as legal challenges destabilize the program. CMS is likely able to address the 10 measures that were tossed over rulemaking deficiencies, but an Act of Congress will be necessary to save the remainders if they’re broadly invalidated. 

These issues lack the high-stakes drama of PBM reform or proposals such as site neutral payments. But they signal that Congress (and the courts) are scrutinizing the health care industry from many angles. Even niche issues can have big ripples in the way health care is financed and delivered, so industry stakeholders must pay close attention even when things feel “quieter” in the policy arena. 

1. Tepper N. Clover Health wins Medicare Advantage star ratings lawsuit. Modern Healthcare. Published May 28, 2026. Accessed June 25, 2026. https://www.modernhealthcare.com/insurance/mh-clover-health-medicare-advantage-star-ratings-lawsuit/
2. Medicines and IP: Balancing Innovation and Access. Hearing before the Subcommittee on Courts, Intellectual Property, Artificial Intelligence, and the Internet of the House Committee on the Judiciary, 119th Cong. June 4, 2026. Accessed June 25, 2026.. https://judiciary.house.gov/committee-activity/hearings/medicines-and-ip-balancing-innovation-and-access 
3. Lowering Health Care Costs for All Americans: Examining Policies to Increase Health Care Transparency. Hearing before the Subcommittee on Health of the House Committee on Energy and Commerce, 119th Cong. June 10, 2026. Accessed June 25, 2026. https://energycommerce.house.gov/events/health-hearing-lowering-health-care-costs-for-all-americans-examining-policies-to-increase-health-care-transparency 
4. Patients Deserve Price Tags Act. H.R. 5582, 119th Cong. (2025). Congress.gov. Accessed June 25, 2026. https://www.congress.gov/bill/119th-congress/house-bill/5582/text 
5. Patients Deserve Price Tags Act. S. 2355, 119th Cong. (2025). Congress.gov. Accessed June 25, 2026. https://www.congress.gov/bill/119th-congress/senate-bill/2355/text 
6. Ensuring Community Access to Pharmacist Services Act. H.R. 3164, 119th Cong. (2025). Congress.gov. Accessed June 25, 2026. https://www.congress.gov/bill/119th-congress/house-bill/3164 
7. PBM Kickback Prohibition Act. H.R. 7895, 119th Cong. (2026). Congress.gov. Accessed June 25, 2026. https://www.congress.gov/bill/119th-congress/house-bill/7895/all-actions

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