Hello, and welcome back to this week’s edition of the Gist Weekly, where we deliver executive-level commentary and insights from the healthcare industry right to your inbox every Friday afternoon. As always, we immensely appreciate your continued readership and invite you to forward this email to friends and colleagues—please encourage them to subscribe as well!
In the News
What happened in healthcare recently—and what we think about it.
- SCOTUS to hear challenge to ACA preventive care mandate. Last Friday, the Supreme Court agreed to review the constitutionality of the Affordable Care Act (ACA) provision requiring insurers to cover preventive care without cost sharing. The plaintiffs for the case, Becerra v. Braidwood Management Inc., are making a religious liberty argument, opposing the mandatory coverage of PrEP HIV medication, and a constitutional argument, questioning the legitimacy of the U.S. Preventive Services Task Force (USPSTF). In June 2024, the 5th Circuit Court of Appeals partially upheld a district court ruling, finding that USPSTF appointees should be confirmed by the Senate but limiting the injunction so that only the plaintiffs did not have to comply with specific parts of the law. The plaintiffs, two Texas-based companies and six individuals, and the defendants, Secretary of Health and Human Services (HHS) Xavier Becerra and other Biden administration officials, both appealed the case to the Supreme Court, but the incoming Trump administration will have discretion to take a different position on the matter. The case will be heard in the coming months, with a decision expected in June.
- The Gist: The ACA has earned a reputation as “the most challenged statute in American history.” Starting with National Federation of Independent Businesses v. Sebelius in 2012, which preserved the individual mandate but made Medicaid expansion optional for states, the ACA has already been upheld three times by the Supreme Court. Unlike the most recent case that sought to strike down the whole law but was dismissed on standing, the Braidwood plaintiffs are specifically targeting the preventive care mandate and coverage requirements for PrEP HIV medications. ACA marketplace plans, which have a record number of enrollees in 2025, do not appear to be in jeopardy, but a victory for the plaintiffs could void the popular preventive care mandate for all insurance plans until USPSTF members receive Senate confirmations.
- Biden’s DEA proposes telehealth rule for controlled substances. On Wednesday, the Drug Enforcement Administration (DEA) released a proposed rule that sets up a three-tier, provider-type-dependent system for the remote prescribing of Schedule II-V controlled substances. The proposed rule dictates that all providers must maintain a state-level registration for states they practice or dispense these drugs in and institutes a requirement, which takes effect three years after finalization, that providers must check Prescription Drug Monitoring Programs for their patients before writing a prescription. Finally, the rule would mandate that at least half of providers’ prescriptions for Schedule II drugs, such as Adderall, must be delivered during in-person appointments. This proposed rule comes after three extensions of Covid-era telehealth flexibilities that allowed clinicians to prescribe controlled substances without an initial in-person appointment, as well as across state lines without a separate DEA registration, contingent on medical licensing. This proposed rule was coupled with a separate finalized rule from the DEA that established a special registration process for telehealth prescriptions of buprenorphine, a Schedule III drug used for opioid use disorder.
- The Gist: Providers, patients, and industry stakeholders have waited patiently for this proposed rule—in the works since at least early 2023—to provide long-term clarity on controlled substance teleprescriptions. Establishing a permanent solution for managing these prescriptions has been a complicated process for regulators, with two previous attempts to get a rule on the books sparking high engagement and vocal opposition from public commenters. The rule functions as a compromise between competing concerns over access and safety, enabling patients to continue enjoying the convenience of telehealth while attempting to disrupt the business model of so-called online “pill mills.” However, the Trump administration will have final say over the fate of both rules, and at least one industry group is already calling on his administration to withdraw the proposed rule.
- FDA announces three new consumer health regulations. On Tuesday, the Food and Drug Administration (FDA) issued a proposed rule to require new nutritional labels for sodium, added sugars, and saturated fats on the front of food packaging. Then on Wednesday, the agency followed up with a proposed rule to severely restrict nicotine content in tobacco products, as well as a ban on the use as a food additive of red dye No. 3, which has been shown to cause cancer in rats. The red dye No. 3 prohibition will go into effect in two years, while the proposed rules on nutritional labels and nicotine content will need to be finalized by the Trump administration. All three agency actions aim to address certain causes of chronic diseases, such as cancer, diabetes, and heart disease.
- The Gist: The timing of these regulatory actions is interesting, given the next administration’s promises to “Make America Healthy Again” (MAHA). Robert F. Kennedy, Jr., Trump’s nominee for HHS Secretary, is a staunch opponent of all food dyes, and Marty Makary, nominated to head the FDA, has emphasized chronic disease prevention over treatment. Although the MAHA movement features some controversial stances on fluoride and vaccines, stronger regulations around nutritional labeling, nicotine content, and food additives are more in line with the public health consensus. California and the European Union have already passed bans against red dye No. 3, and similar food-labeling regulations in the Netherlands and Chile produced positive changes in consumer behavior.
Plus—what we’ve been reading.
- Progress in painkiller drug development. Published in the Washington Post earlier this week, this piece details a pivotal update in researchers’ quest for the next generation of powerful painkillers. Efforts to date “have ended in frustration,” but Vertex Pharmaceuticals has an application before the FDA for suzetrigine, a strong, non-opioid pain killer. Notably, Vertex claims that the drug minimizes addiction risk by targeting a gateway in the spinal cord rather than the brain directly. Initial clinical trials demonstrated that the drug was very effective for patients recovering from two different kinds of surgery. However, research testing the drug’s utility for managing chronic pain remains ongoing. While the drug remains “promising but inconclusive,” building trust in a skeptical patient population may be the larger challenge. As one patient put it, “When new drugs come out, I don’t want to be the first one taking it.”
- The Gist: This treatment could be a transformative breakthrough, as over 20% of Americans are managing chronic pain without safe and effective long-term medication options. However, claims of nonaddictive pain medication immediately draw comparison to the opioid crisis, which has generated justified skepticism of any addiction-risk claims. Pharmaceutical companies like Purdue Pharma severely downplayed these risks in aggressive marketing schemes that fueled the crisis, with many communities still reeling from the losses. If this drug is ultimately proven effective, providers’ role in rebuilding this lost trust with a reluctant public will be paramount to delivering the highest level of care.
Graphic of the Week
A key insight illustrated in infographic form.
PSHPs report better preventative care outcomes
Following last week’s graphic on Medicare Advantage (MA) star ratings, this week we highlight how different types of MA plans perform along certain patient outcomes metrics. The HD1 indicator, for example, calculates the number of beneficiaries that receive certain physical preventive care including cancer screenings and annual flu shots. From 2019 through 2025, provider-sponsored health plans (PSHPs) consistently earned a higher HD1 score than their competitors. The average HD1 rating for a PSHP in 2025 is 3.83, which compares favorably to the 3.63 average for BUCCAH plans (referring to six of the largest traditional payers), and a 3.24 average for all other plans. This difference in average HD1 scores is particularly remarkable for the annual flu shot indicator, labeled C03. In 2025, PSHPs had an average rating of 3.99 contrasting with a 2.94 average for BUCCAH plans and a 3.13 average for all other plans. The strong performance of PSHPs may be explained by their incentives for clinical and management sides to collaborate, easing patients’ journey throughout the care continuum. In addition to these positive primary care results, PSHP beneficiaries report a higher satisfaction with their plans than their counterparts. The average HD3 measure, or a member experience score that quantifies members’ access to and quality of care, is higher for PSHPs than their competitors. Once again, PSHPs are likely reaping the benefits of vertically integrating their payer and provider arms. They are better positioned to manage and coordinate the care of their beneficiaries, especially for primary care, giving PSHPs a strong competitive edge.
This Week at Kaufman Hall
What our experts are saying about key issues in healthcare.
Many individuals working in healthcare were stunned by the reaction of much of the American public to the murder of UnitedHealthcare CEO Brian Thompson. The assassination triggered a wave of social media posts and press reports that laid bare the rage that many in this country feel toward the health insurance companies, but likely also every component of the healthcare delivery system. While inappropriate, the reaction to the Thompson murder suggests that America’s healthcare consumers may want something very different from the healthcare delivery system than what they currently believe they are receiving.
In his latest blog, Kaufman Hall Managing Director and Founder Ken Kaufman considers the implications of the Thompson murder for the healthcare delivery system as a whole. Central to his observations is this key point: The overall healthcare system is no longer felt as personal by much of the American public and this rising impersonality is the source of much of the frustration the American healthcare consumer feels today.
On Our Podcast
The Gist Healthcare Podcast—all the headlines in healthcare policy, business, and more, in ten minutes or less every other weekday morning.
Monday interview episodes will be returning in the coming weeks. In the meantime, our Gist Healthcare Daily podcast covered many of the week’s other big stories, including:
- CMS expands enforcement power over ACA brokers
- Walgreens moves ahead with plans to sell VillageMD
- Enrollment drops for Black and Hispanic medical students following SCOTUS Affirmative Action ruling
To stay up to date, be sure to tune in every Monday, Wednesday, and Friday morning. Subscribe on Apple, Spotify, Google, or wherever fine podcasts are available. (As a programming note, there will be no new episode this Monday, in observation of Martin Luther King, Jr. Day.)
Thanks for reading! We’ll see you next Friday with a new edition and wish you a happy MLK weekend. In the meantime, check out our Gist Weekly archive if you’d like to peruse past editions. We also have all of our recent “Graphics of the Week” available here.
Best regards,
The Gist Weekly team at Kaufman Hall
