Transparency, Fraud, and Midterms Shape Federal Health Policy Outlook

Federal health policy faces competing priorities around transparency, health care costs, and fraud prevention, with the outcome of the 2026 midterm elections potentially shaping what Congress can accomplish, according to Adam Colborn, JD, vice president of government affairs at the Academy of Managed Care Pharmacy (AMCP), in part 2 of an interview at AMCP Nexus 2026.

Colborn, a panelist in the “Federal Legislative and Regulatory Update” session, noted that the Lower Costs, More Transparency Act of 2023 included a ban on spread pricing in Medicaid, which the 2026 version omits. Both versions require pharmacy benefit managers, insurers, hospitals, and other providers to report on claims and revenue. He questioned the value of the hospital price reporting requirement because chargemaster prices do not reflect what patients or insurers actually pay.

Colborn also described the federal government's approach to combating health care fraud, waste, and abuse as “a little bit of a mixed bag.” He pointed to CMS's actions on skin substitutes as an example of the agency “doing the right thing.” A quirk in CMS reimbursement policy had allowed manufacturers to relaunch these costly wound care products with marginal changes to qualify for higher reimbursement, despite their minimal clinical benefit.

Some other CMS efforts to combat fraud have taken on a more partisan tone, Colborn noted. For example, Medicaid payments to some Democratic-leaning states have been deferred over fraud concerns, even when those allegations have not been proven. He said that some of these states have also been actively working to address the same fraud.

Colborn also raised concerns about new prior authorization requirements for 3 procedures under traditional Medicare. The firms conducting these artificial intelligence–driven reviews are paid based on the savings they generate, he explained, creating an incentive to deny care.

Lastly, with the interview conducted shortly before the midterm elections on November 3, Colborn said divided government would limit what Congress could accomplish, even if Democrats won both chambers, because Republicans would retain control of the White House.

“I would say we will probably see more aggressive attempts from Congress on drug pricing and the cost of health care generally if Democrats win, but I don't know that it will translate to laws passed,” he concluded.