The Healthcare Plan That Still Needs A Plan

Yesterday, the White House unveiled the Great Healthcare Plan, a framework for the administration’s ambitions to reshape aspects of the US healthcare system. This follows a series of failed attempts to revive Affordable Care Act (ACA) premium subsidies, a key pillar of the current conversation around healthcare affordability. The expiration of ACA subsidies, combined with higher premiums, is the straw that’s breaking the camel’s back. All of this comes wrapped in the cloak of opacity, as industry jargon and performative regulatory compliance leave consumers unprepared when bills arrive.

The Outline Of The Plan

The plan comprises five major themes that aim to tackle some of the toughest issues in the industry. Some truly promising proposals reflect consumer-oriented initiatives we’ve long championed as essential for earning trust and sustaining lasting customer relationships, but the plan is only a one-page outline, handed from the White House to Congress so lawmakers can fill in the details. This can lead to unintended consequences. The plan’s themes are:

Lower drug prices. The plan aims to lower drug costs through most favored nation pricing, shifting more medications to over‑the‑counter (OTC) to increase competition and eliminating pharmacy benefit manager kickbacks that inflate costs. Mentions of a “cost-sharing reduction program” contained no details of how it could save taxpayers $36 billion or reduce ACA plan premiums by 10%.

Things to consider: Pharmacy repackaging is a big, costly, and potentially risky overhaul. Bypassing pharmacists can remove critical clinical oversight, increasing the risk to patients. Additionally, retooling for consumer-ready packaging will take time to implement — for both manufacturers and retailers.

Lower insurance premiums. The plan favors sending subsidies directly to qualified individuals, bypassing ACA exchanges. The framework doesn’t specify eligibility requirements or the size of the payments.

Things to consider: Sending money directly to consumers raises two issues: The payment may not be high enough, and people may spend the money elsewhere. These possibilities could leave consumers unable to pay for insurance or treatment, leaving medical needs unaddressed. Delaying or deferring care can put stress on the delivery system (such as emergency departments) and remove healthier patients from the risk pool, leading to higher insurance premiums.

Increasing accountability of insurance companies. The ACA required tightly managing overhead expenses, but it stopped short of managing their disclosure. The plan demands that insurers publish the share of revenue spent on claims vs. overhead and profit, unmasking inefficiency or price inflation. It also instructs insurers to report claim denial rates and average wait times for routine care.

Things to consider: Insurers can already publish expense and denial information on their websites. Wait times may be more challenging to calculate, but we’ll have to wait to see what’s considered “routine care” before we can understand the problem more fully. Capturing the wait for a “routine” physical is different than for a “routine” mammogram.

Improving coverage understanding. The plan mandates a “plain English” insurance standard, forcing insurers to present premiums and coverage details clearly on their websites. It also requires insurers to provide side‑by‑side premium and coverage comparisons in a standardized format so that consumers can easily shop across plans.

Things to consider: Despite attempts to standardize consumer-friendly materials across insurers since 2012, health insurers are missing the mark. Over one-third of consumers disagree that the information their health insurer provides is easy to understand, and 35% reach out with questions on coverage. As the use of generative AI tools by consumers proliferates, health insurers must assume that AI will be in the mix, and they will need to incorporate it into whatever they implement.

Amplifying price transparency. All Medicare/Medicaid‑accepting providers will have to prominently post their pricing, reducing surprise billing and broadening transparency beyond hospitals. Current law has done little to improve pricing clarity and protect patients. Compliance is uneven, data is hard to use, and consumer materials are opaque.

Things to consider: To an extent, this is the logical next step in what providers and insurers have already been tasked to do. The details, including penalties for noncompliance, will determine how the plan is supposed to work and whether it will avoid the inconsistent and performative actions that have proven existing laws ineffective.

What’s Next

It’s up to Congress to define the plan’s details. We will be watching to see how lawmakers translate these concepts into actionable legislation. For now, healthcare organizations can get ahead of this and help steer the direction of the legislation by considering:

What’s doable today. Health insurers already know their administrative expenses, medical loss ratio, and denial rates. Post them now. Also, figure out how to work together to create plain-language communication standards.
What needs more planning. Not all providers can calculate wait times today, but some do have technology that can forecast estimates. Similarly, pharma firms need to start identifying good OTC candidates.
What can be influenced. Healthcare organizations can proactively comply with elements of the plan, working together as an industry to shape the legislation’s direction before it becomes law.

Where do you go from here? If you’re a Forrester client, start by reaching out for a guidance session to discuss your specific questions.

If you’re not yet a client, please reach out to our sales team to learn about how we can help you work through the changes as they unfold. And look for future blogs as the legislation winds its way through a Congress dealing with midterm elections.