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LUGPA Policy Update: House Passes Limited Healthcare Bill; ACA Subsidies Expire; Physician Payment and Drug Pricing Uncertainty Continues

January 2026

At-a-Glance Essentials

Why It Matters

Coverage and Access at Risk
The expiration of EPTCs is expected to significantly increase Marketplace premiums in 2026—potentially doubling on average for many enrollees. Higher premiums are likely to reduce enrollment, increase churn, and disrupt coverage continuity, with downstream effects on patient access to specialty and preventive care.

Ongoing Physician Payment Instability
Short-term payment patches continue to mask decades of real-term declines in Medicare payments. Without permanent, inflation-adjusted updates tied to practice cost growth, independent physician practices face growing financial strain that threatens access to community-based specialty care.

Drug Pricing Policy Uncertainty
While CMS preserved ASP + 6 percent reimbursement, layered drug-pricing initiatives—including GLOBE, GUARD, and MFN agreements—create uncertainty about manufacturers' pricing behavior, product availability, and future payment policy for physician-administered therapies.

Cumulative Policy Pressure on Specialty Care
Taken together, expiring coverage subsidies, temporary physician payment relief, and expanded drug-pricing demonstrations increase uncertainty for independent practices, with no clear safeguards for access to specialty care or sustainability.

Key Dates

  • Enhanced Premium Tax Credits expired: December 31, 2025
  • CY 2026 Medicare Physician Fee Schedule effective: January 1, 2026
  • GLOBE/GUARD public comment deadline: February 23, 2026
  • Proposed GLOBE model period: October 2026 – September 2031 (rebates through 2033)
  • Proposed GUARD model period: January 2027 – December 2031 (rebates through 2033)

Additional Context

No Comprehensive End-of-Year Legislative Package

Despite bipartisan negotiations, Congress adjourned without enacting structural Medicare physician payment reform. While the one-time CY 2026 update temporarily stabilizes payments, it does not address the lack of annual updates tied to the Medicare Economic Index (MEI) or the rising practice costs, including staffing, supplies, technology, and compliance requirements.

LUGPA continues to advocate for permanent, predictable, and inflation-adjusted Medicare payment updates to protect patient access to independent urology care and ensure long-term practice sustainability.

ASP + 6% Drug Reimbursement Maintained

CMS finalized no changes to the ASP + 6 percent Part B payment methodology for CY 2026. This decision preserves the viability of in-office oncology and injectable therapies and prevents further shifts in care to higher-cost hospital outpatient departments. Maintaining ASP + 6 percent remains a core LUGPA priority to support community-based cancer care and patient convenience.

CMMI’s GLOBE and GUARD Drug Pricing Models

CMS emphasized that both models are designed to target manufacturer inflation rebates—not provider reimbursement.

  • GLOBE (Part B): Applies to select single-source drugs, including oncology therapies, using alternative rebate benchmarks tied in part to international pricing.
  • GUARD (Part D): Extends the concepts to Part D drugs, complementing the Inflation Reduction Act's negotiation authorities.

Rebates under both models are excluded from ASP and Medicaid Best Price calculations. However, CMS acknowledged that indirect effects on manufacturer pricing behavior, product availability, launch strategies, and market participation are possible. Voluntary pricing agreements may allow some manufacturers to opt out of the models.

LUGPA is closely monitoring these proposals to ensure that drug pricing reforms do not unintentionally restrict access to essential therapies or undermine community-based specialty care.

Key Clarifications on GLOBE and GUARD

  • Statutory Scope: Both the GLOBE (Part B) and GUARD (Part D) models explicitly exclude drugs subject to Medicare Drug Price Negotiation (MFP) under the Inflation Reduction Act.
  • Current Reimbursement Framework: Based on CMS guidance to date, ASP + 6 percent reimbursement is preserved under both proposed models.
  • Material Risk to Office-Based Care: While ASP + 6 percent technically remains in place, any significant downward pressure on ASP—or a future shift away from ASP to alternative benchmarks (e.g., MFP or MFN)—could substantially erode the effective add-on payment. Such erosion would threaten the financial sustainability of delivering cancer and complex therapies in physician office settings.
  • Policy Implication: These risks underscore the importance of H.R. 4299, the Protecting Patient Access to Cancer and Complex Therapies Act, which would provide needed payment stability and help ensure patients can continue receiving essential treatments in lower-cost, community-based settings.

House-Passed Healthcare Bill and ACA Marketplace Outlook

The House-passed Lower Health Care Premiums for All Americans Act expands association health plans and increases PBM transparency but does not extend enhanced ACA subsidies. Without congressional action, Marketplace enrollees face higher premiums, reduced plan affordability, and increased risk of coverage loss in 2026.

Bipartisan efforts, including a planned discharge petition, could force a vote on a clean EPTC extension early in 2026. LUGPA continues to monitor these developments for their impact on patient coverage, access to specialty care, and practice stability.

LUGPA Advocacy Position

LUGPA remains focused on advancing policies that:

  • Secure permanent, inflation-adjusted Medicare physician payment updates
  • Preserve ASP + 6 percent reimbursement for physician-administered therapies
  • Ensure drug pricing reforms protect patient access and physician-led care
  • Prevent coverage disruptions that undermine continuity of care
  • Support independent practices as a cost-effective, patient-centered care model

Bottom Line

As 2025 concludes, federal healthcare policy remains defined by short-term fixes, expiring coverage supports, and growing uncertainty around payment and drug pricing reforms. Without sustained legislative action, independent urology practices—and the patients they serve—will continue to face instability.

LUGPA remains actively engaged with Congress, CMS, and CMMI to protect patient access, preserve the viability of independent practice, and advance a more stable and sustainable healthcare policy framework in 2026 and beyond.