Health Care Policy Debates to Watch Ahead of the 2026 Midterms

As we approach the 2026 midterm elections, members of Congress are working hard to spotlight actions they have taken or will take if their party wins control next year. Many are touting their ability to work across the aisle on bipartisan policy solutions. As always, health care is a major focus in campaign messaging. These are a few specific issues I’m watching as we anticipate the incoming Congress of 2027: 

• Requests for information (RFIs) from Senate Finance Democrats on drug pricing and health coverage
• A growing set of proposals to reform the 340B drug purchasing program
• The September 15, 2026, hearing in the House Committee on Energy and Commerce on Medicare provider bills¹ 

All 3 address the highly salient political issue of health care spending as voters head to the polls. Let’s take a closer look at each issue.

Democrats on the powerful Senate Finance Committee published 2 RFIs on health care costs over the summer: Commonsense Policy Options to Lower Drug Prices for Patients and Health Coverage That Works for Everyone.^2,3 This was expected to be a tough year for Democrats in the Senate, but a surprisingly competitive map has party leaders mapping out an agenda in case they flip the upper chamber. Without getting too deep into the partisan weeds, Democrats see health care issues as one of their strongest areas. However, they also feel that President Trump’s high-profile actions, including TrumpRx and the Most Favored Nation Model, demand a response that cements Democrats’ ownership of the issue.

That brings us to the RFIs. In addition to seeking ideas from respondents, Democrats also propose a series of policy solutions intended to lower costs and improve access. The proposals are diverse and, in some cases, contradictory. For example, the drug pricing RFI describes a desire to move away from drug margin as a source of pharmacy revenue, but in another section, suggests using National Average Drug Acquisition Cost (NADAC) plus a dispensing fee as a standardized reimbursement, which would allow pharmacies to retain margin (at least for a time) by purchasing multisource generics at a below-NADAC price. The RFI also argues that patients pay too much for low-cost generic drugs when using their benefits while also proposing to raise dispensing fees paid to pharmacies on those same drugs, which would result in a higher overall spend.

The health coverage RFI is a little more open-ended than the drug pricing one and contains, in my opinion, the more interesting set of policy ideas. Here are a few of the highlights:

• A centralized enrollment platform for all types of coverage, including employer-sponsored benefits, exchange plans, and Medicaid
• “A coverage system that provides all Americans with a Medicare-type choice”
• Additional limitations on prior authorization and claims denials used to “generate profits and limit access to care”
• Creating new safeguards to minimize churn based on income fluctuations
• Repeals of the H.R. 1 changes to Medicaid, such as work requirements and reduced funding levels

Some of these proposals would reform aspects of commercial health insurance while preserving the largely privatized system, whereas others would move the United States toward a more public system.

The section titled “Establishing a Federal Option” is probably what will give the managed care community the most turmoil. It stops short of calling for a single-payer “Medicare-for-All” system while resurrecting the “public option” discussion from the Affordable Care Act and 2020 Democratic presidential primary. Conservatives, however, have long argued that a public option is really a backdoor for a Medicare-for-All system that would usher in the end of private insurance.4 Given the popularity of Medicare Advantage, I’m not totally sure that’s true. It’s not hard to imagine a robust supplemental insurance market in a Medicare-for-All system, but it would certainly reduce the market for privatized benefits (not to mention its implications for employers).

These RFIs should be viewed as a set of options rather than a to-do list. However, managed care professionals should closely monitor the Senate Finance Committee Democrats for proposals aligned with the RFIs. The proposals range from minor to truly significant and are likely to inform the playbook for future elections and Congressional action.

Once a niche issue, the 340B drug pricing program has become a focal point in the debate about health care costs (at least in Washington, DC). Through this program, hospitals buy drugs at a discounted rate but receive the full reimbursement amount; it has become the second largest drug purchasing program in the country behind Part D, with purchases reaching almost $200 billion in total value in 2025.⁵ There’s some debate about the original intent of the program, but the prevailing opinion is that it was created primarily as a safety net and to keep nonprofit hospitals afloat during a time of financial instability. However, the financial outlook for many nonprofit hospitals has changed substantially since 340B launched in 1992. 

With pharmacy benefit management reform out of the way, lawmakers have turned their attention to other segments of the health care industry. Hospitals are the largest source of spending, accounting for about 40% of cost growth,⁶ so they’re a natural target. There are four main federal proposals⁷:

1. 340B Drug Pricing Integrity and Affordability for Patients Act (340B for Patients Act) discussion draft
2. Supporting Underserved and Strengthening Transparency, Accountability, and Integrity Now and for the Future of 340B Act (SUSTAIN 340B Act)
3. Strengthening the Exercise of Controls and Upgrading Requirements for Efficiency in 340B Act (SECURE 340B Act)
4. 340B Affording Care for Communities and Ensuring a Strong Safety-Net Act (340B ACCESS Act)

Each bill proposes reform that would reduce the volume of 340B drugs dispensed, but they vary in scope and on some key subjects. Further, 2 of the bills—340B for Patients Act and 340B ACCESS Act—are partisan and led by members of Congress who are not returning in 2027. 

I don’t expect any legislation to pass this year given the high stakes of the debate, so we’ll focus on the SUSTAIN and SECURE acts because they have a greater chance of being reintroduced in Congress next year. SUSTAIN and SECURE are bipartisan bills. SUSTAIN is a Senate bill sometimes called the “Gang of Six bill,” in reference to the bipartisan group of 6 Senators leading it. The SECURE 340B Act is a House-led effort. 

Perhaps the single most significant piece of 340B reform is the creation of a patient definition. The law does not currently define patient eligibility of a 340B covered entity (CE). Creation of a definition allows patients with very tenuous relationships to the CE, such as a simple telehealth consultation, to receive drugs from a contract pharmacy’s 340B inventory, resulting in additional revenue for the CE and contract pharmacy. In some cases, these telehealth visits are part of alternative funding models that share 340B savings with employers. Both SUSTAIN and SECURE would create a patient definition that requires patients to have more robust connections to a CE to receive a 340B-eligible prescription. 

Another contentious element of the 340B program is the use of contract pharmacies. At the start of the program, CEs could have only one contractual relationship with an outside retail pharmacy to dispense 340B prescriptions. In 2010, the Health Resources and Services Administration finalized guidance that allowed for an unlimited amount of contract pharmacy relationships. Critics have pointed to this as a major driver of 340B revenue growth; the rationale is that CEs are able to put contract pharmacies in wealthy neighborhoods and better payer mixes but with no relationship to the community primarily served by the CE. Both SUSTAIN and SECURE would allow the continued use of an unlimited number of contract pharmacies but impose additional oversight and transparency requirements.

Addressing the patient definition question probably goes a long way toward fixing many of the problems people have with contract pharmacies. Limited availability of contract pharmacies is an indirect method of controlling the total universe of patients and, consequently, the volume of 340B prescriptions. Many patients have legitimate relationships with somewhat distant hospitals, particularly when seeking specialized care. For those patients, there’s a sound argument for having pharmacies available in convenient locations. 

But the patient definition is a very thorny political question. If agreement can’t be reached, limiting contract pharmacies—Senator Bill Cassidy proposed a maximum of 5 in the 340B for Patients draft—may be the only option to control growth for now.

Medicare has long been a potent political force, both for its beneficiaries and health care providers. The “doc fix,” a series of temporary bills that delay cuts to Medicare payment rates due to a 1997 law, has become something of a legislative ritual in Washington. At a September 15 hearing, the Energy & Commerce Health Subcommittee considered this year’s doc fix and other Medicare-related bills, including the Alzheimer's Screening and Prevention (ASAP) Act to provide for biomarker tests for Alzheimer’s, the Kidney Care Access Protection Act to boost Medicare services for end-stage renal disease, and the Ensuring Community Access to Pharmacy Services Act to allow pharmacists to receive Part B reimbursement for administering tests and treatment for respiratory illness.

Notably, this hearing focused on bills with bipartisan support, which suggests these bills that could have a real shot at reaching the finish line this year; none of these are simple messaging bills. Also, Republicans may be looking to generate some good news on health care heading into the midterm election. Historically, midterms are usually tough for the incumbent president’s party, suggesting that control of the House is likely to switch parties. Medicare beneficiaries are a highly engaged group of voters, so a health care win could deliver a boost, especially for swing-district incumbents. 
The inevitable question is how many of these bills will pass before Election Day. Process and precedent suggest a pessimistic outlook. A hearing is only the second step of regular order in the House. Bills still typically need to go through the mark-up process (possibly through multiple committees), a floor vote, and passage in the Senate. That’s a lot to do between now and November 3. But this hearing is still important. It sets up these bills for inclusion in a possible year-end package, and it gets the attention of voters who are closely following these bills, such as physicians and patient advocates.

Ultimately, health care is just one part of the affordability discussion driving this year’s elections, alongside such concerns as grocery and gas prices. But for many voters, health care has emotional and personal significance that often places it at the top of the list. As the Senate and the House of Representatives face a highly competitive midterm election, there is opportunity for legislation to move faster than usual as elected officials seek a return to office. 

References

1. Health Hearing: Examining Legislative Proposals to Reform Medicare Provider Payment and Bolster Health Care Cybersecurity. Before the House Committee on Energy and Commerce, Subcommittee on Health, 119th Cong, 2nd Sess (September 15, 2026). Accessed September 22, 2026. https://energycommerce.house.gov/events/health-hearing-examining-legislative-proposals-to-reform-medicare-provider-payment-and-bolster-health-care-cybersecurity

2. US Senate Committee on Finance, Minority Staff. Request for Information: Commonsense Policy Options to Lower Drug Prices for Patients. June 16, 2026. Accessed September 22, 2026. https://www.finance.senate.gov/imo/media/doc/061626_sfc_drug_pricing_rfi.pdf 

3. US Senate Committee on Finance, Democratic Staff. Request for Information: Health Coverage That Works for Everyone. July 30, 2026. Accessed September 22, 2026. https://www.finance.senate.gov/imo/media/doc/073026_sfc_health_coverage_rfi.pdf 

4. Atlas SW. Public option kills private insurance. The Wall Street Journal. Updated July 16, 2019. Accessed September 22, 2026. https://www.wsj.com/articles/public-option-kills-private-insurance-11563309118  

5. Martin R, Karne H, Zeng S. The size and growth of the 340B program in 2025. IQVIA. 2026. Accessed September 22, 2026. https://www.iqvia.com/-/media/iqvia/pdfs/us/white-paper/2026/iqvia-size--growth-of-340b-in-2025-white-paper-2026.pdf  

6. Godwin J, Levinson Z, Neuman T. Hospital spending accounted for 40% of the growth in national health spending between 2022 and 2024. KFF. February 11, 2026. Accessed September 22, 2026. https://www.kff.org/health-costs/hospital-spending-accounted-for-40-of-the-growth-in-national-health-spending-between-2022-and-2024/

7. Academy of Managed Care Pharmacy. Comparison of 340 Reform Proposals in the 119th Congress. Published September 11, 2026. Accessed September 28, 2026. https://www.amcp.org/sites/default/files/2026-09/340B%20Legislation%20Chart%20-%20119th%20Congress%20.pdf

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