Broadening the Focus: A New Framework for Evaluating Health Care Programs
Health Equity Committee Chairperson Becky Sheppard offered insight on the Health Practice Council’s Broadening the Focus initiative.
Coming out of the Health Practice Council’s (HPC) successful April Virtual Health Summit, the Health Equity Committee (HEC) continues to advance the new Broadening the Focus framework, a practical tool to support more holistic evaluation of health care programs and benefit design.
At its core, the framework responds to a familiar challenge: decisions are often driven by short- term financial return on investment (ROI), which can overlook important outcomes such as long-term health improvements, access, and equity.
What’s New?
The framework expands the lens of evaluation to include both financial and non-financial impacts, recognizing that program value extends beyond immediate cost savings.
- Considers clinical, equity, operational, and societal outcomes, alongside cost.
- Highlights indirect costs and benefits, including long-term and cross-sector impacts.
- Encourages use of complementary metrics (e.g., health outcomes, access, engagement, and cost-effectiveness).
- Emphasizes clear, cross-disciplinary communication to ensure results are understood and actionable.
How the Framework Works
Rather than prescribing a specific method, the framework is principles-based and flexible. It is designed to guide questions, not replace existing actuarial or evaluation approaches.
It organizes evaluations across five core domains:
- Framing: Goals, constraints, context.
- Stakeholders: Who is affected and their priorities.
- Benefits: Financial and non-financial outcomes.
- Costs: Including timing, distribution, and opportunity costs.
- Measurement: Methods, data quality, and communication.
These domains help ensure that key considerations, such as who benefits, when outcomes emerge, and how uncertainty is addressed, are systematically thought about during decision-making.
Why it Matters
By broadening the focus beyond ROI alone, the framework supports more balanced, transparent, and decision-relevant evaluations, ultimately helping to better align health care spending with improved outcomes, access, and long-term value.
Looking Ahead
The framework is designed to evolve through real-world use. Ongoing engagement with employers, insurers, providers, and policymakers will continue to shape and refine the approach, ensuring it remains practical and relevant for those making complex health care decisions.
▶ SOA Health Meeting—The HPC/HEC will present on the framework at the upcoming Society of Actuaries (SOA) Health Meeting, June 29–30 in Washington, D.C.
▶ Read more—For more on the Broadening the Focus framework, check out the Actuarially Sound blog post.
VP Corner
Summertime, and the HPC’s Policy Outreach Continues
Annette James, Vice President, Health
The summer weather is heating up but the Health Practice Council is not slowing down!
As you can see in this issue of HealthCheck, the Health Equity Committee, led by Chairperson Becky Sheppard, is continuing to get the word out on Broadening the Focus, which the HPC unveiled earlier this year in our very well-received April Virtual Health Summit. Look for more on this work and our ongoing engagement with various stakeholders in the months ahead.
Also in this issue, HPC Co-Vice Chairperson Susan Pantely’s testimony on behalf of the Academy at a May 1 hearing of the Texas House Select Committee on Health Care Affordability showed the importance of the Academy offering a balanced and objective actuarial perspective in our health public policy work. These ongoing conversations around access, affordability, and costs have never been more important or as potentially politically challenging as they seem to be today. Which is why the HPC and the Academy work incredibly hard to be at the table, sharing our expertise and our knowledge, when policymakers try to make sense of the underlying problems and develop potential solutions.
These conversations with policymakers also provide the HPC with opportunities for new projects or priorities. An example of this is the new Joint Long-Term Care (LTC) Combo Committee. This joint committee pulls together the HPC and the Life Practice Council to focus attention on the challenges facing consumers who are looking for more affordable LTC coverage and services.
With increasing focus on combination products that integrate life insurance or annuities with LTC coverage, this committee will ensure that we’re able to develop balanced and timely information related to these combo products, including educational content and responding to regulatory questions about design, pricing, risk mitigation, and experience studies. As a new joint committee, we are seeking members with experience in long-term care from health and life perspectives. Please reach out to the Academy’s Public Policy department if you would like to volunteer.
▶ Volunteers welcome—Beyond the new joint committee, the HPC always welcomes new volunteers! If interested, please submit your interest via the Academy’s volunteer contact form.
Academy Holds Virtual Health Summit
The HPC’s April 16 Virtual Health Summit put a spotlight on the “Broadening the Focus” series of issue briefs, as the HPC released Unveiling the Framework, a holistic, principles-based approach to evaluating health care programs and benefits. Presenters included Academy HEC Chairperson Becky Sheppard and member Ugo Okpewho, who introduced and gave an overview of the framework (see related lead story).
Designed for use by actuaries and other stakeholders, the framework complements traditional financial metrics and evaluations and is intended to provide support to decision-makers in their evaluations. Summit presenters discussed issues in health care and explored how a more holistic evaluation approach can improve health care access and affordability.
Dr. Rishi Manchanda, founder and President of HealthBegins, gave the opening keynote presentation. “The Broadening the Focus framework is already being looked at by many nonactuarial leaders across the country—especially those who are part of this emerging network and are thinking about what it would take to help unlock and align new capital flows and financing for health equity,” Manchanda said. “What the Academy is doing is vanguard—there are people out there noticing, and I can’t celebrate that enough.”
HPC Testifies to Texas House on Health Affordability
HPC Co-Vice Chairperson Susan Pantely testified on behalf of the Academy at a May 1 hearing of the Texas House Select Committee on Health Care Affordability. Pantely shared insights from the Academy’s work on premium rate development, the value of stable and competitive health insurance markets, and other points as the committee explores the important issue of affordability—one of the key issues identified by the Academy’s online Policy Forum.
In addition to the Academy, the committee heard from academics, a practicing physician, private consultants, and representatives from the National Academy for State Health Policy and the Kaiser Family Foundation. Over the course of two days of hearings, panels focused on providing a general overview of the system, hospitals, pharmaceuticals, insurance, and state purchasers.
▶ Watch the testimony—Watch Pantely’s opening statement here.
▶ Read more—Read the Academy testimony, and see the Actuarially Sound blog post on the hearing.
New Joint LTC Combo Committee Seeking Volunteers
The Academy’s new Joint Long-Term Care (LTC) Combo Committee is seeking members with experience in one or more of the following: traditional long-term care insurance, LTC combination products, LTC riders, and related areas. The committee is charged with monitoring, responding to, and educating about the various aspects of products that combine features of life insurance policies or annuity contracts with LTC coverage. Actuaries with life insurance, health insurance, and cross-practice expertise are all encouraged to apply. Please reach out to the Academy’s public policy staff (publicpolicy@actuary.org) with questions or if you are interested in volunteering.
Academy Offers Health Perspective at Inaugural FIMCON
HEC Chairperson Becky Sheppard represented the Academy, bringing an actuarial perspective to a June 1 panel discussion at FIMCON, a new “Food Is Medicine” conference held in Washington, D.C. In “Advancing & Sustaining Food Is Medicine Through a Value-Based Care Lens,” Sheppard shared and discussed the HEC’s holistic, principles-based “Broadening the Focus” framework, unveiled in April, for evaluating health care programs and benefits, which complements traditional financial metrics and program evaluations.
Public Policy Health Outreach
Active Benefits Committee Chairperson Ben Rayburn led a virtual session on trends in the employer health insurance market at the Association of Federal Health Organizations’ May 6 meeting, highlighting coverage sources and factors contributing to rising health care costs, and providing an actuarial lens to the group, which represents carriers serving federal government and postal employees and retirees.
▶ Speakers Bureau—The Academy’s Speakers Bureau provides qualified speakers to actuarial clubs, employers, and educational entities on professionalism and public policy topics.
Medicare Trustees Report Released; Webinar, Issue Brief Coming Soon
The 2026 Social Security and Medicare trustees’ reports were released June 9.
Medicare’s Hospital Insurance (HI) Trust Fund will be able to pay 100% of benefits until the second quarter of 2033, one quarter earlier than projected last year, according to the report. At that point, that fund’s reserves will become will be sufficient to pay 89% of scheduled benefits. The Supplementary Medical Insurance (SMI) Trust Fund is adequately financed into the indefinite future because, unlike other trust funds, its main financing sources are adjusted annually to cover costs for the upcoming year.
▶ Alert, issue briefs, webinar—An Academy alert (member login required) offers more details on the reports, and the HPC and the Retirement Practice Council are preparing issue briefs on the reports, and the HPC will also hold its annual webinar on the report soon.
Webinar Covers Medicaid, Upcoming Practice Note
Medicaid Committee members led a June 16 health webinar, Enhancing Medicaid Risk Adjustment: Insights from the New Practice Note, on the committee’s forthcoming practice note on actuarial services involving the application of risk adjustment models within Medicaid managed-care programs. Watch a replay on Academy Learning.
Highlights From
HealthCheck
Prefer to watch your news? Check out this “Highlights From HealthCheck” video for a quick recap of what you need to know.
ASB Approves ASOP Nos. 45, 49 Exposure Drafts
The Actuarial Standards Board (ASB) approved exposure drafts of proposed revisions to Actuarial Standard of Practice (ASOP) No. 45, The Use of Health Status-Based Risk Adjustment Methodologies, and ASOP No. 49, now titled Medicaid Managed Care Capitation Rates. Information on how to submit comments can be found in the drafts. Comments on both are due by Sept. 1.
ASOPs—Your Feedback Wanted
The Academy and the Actuarial Standards Board (ASB) want your feedback on how you use and access actuarial standards of practice (ASOPs).
To take a short, five-question survey about how you access the ASOPs, click here.
Early Discounts Available for LHQ Seminar
Early registration discounts are available for the 2026 Life and Health Qualifications Seminar, to be held Sept. 28–Oct. 1 in Arlington, Va., just outside Washington, D.C. Similar to last year, separate life and health tracks will follow a day of general education.
Registration is limited for the popular seminar, which delivers three days of training and instruction and an optional three-hour exam on the fourth day. The seminar has also been moved to September from its traditional November timeframe, based on attendee feedback.
Secure your early discount and join us in September. Register today.
Academy in the News
Individual and Small Group Markets Committee member Matt Mize provided an actuarial perspective to Politico on the implications of proposed regulatory changes for the individual health insurance market.
North Texas’ KERA News and other National Public Radio affiliates in the state covered the HPC’s testimony before a Texas House select committee.
A Bloomberg Law story on the Centers for Medicare & Medicaid Services’ proposed rule on 2027 benefit and payment parameters highlighted questions about the rule’s proposed expansion of catastrophic plans which the Academy expressed in a March comment letter.
Academy background material on rate development was cited in a story on small business health insurance challenges by the Michigan State University School of Journalism.
A California Health Care Foundation paper arguing for consideration of a Medicaid per-capita cap in the state’s program cited last year’s Medicaid Committee issue brief on per-capita caps for background.
Inside Health Policy‘s (subscriber-only) coverage of health issues at the NAIC Spring National Meeting highlighted the Health Equity Committee’s March 13 comments on the annual Notice of Benefit and Payment Parameters.
MedCity News cited the Academy’s FAQs on risk pooling.
Legislative/
Regulatory Activity
Federal
The Trump administration announced in May that it was withholding $1.3 billion in Medicaid funding from California, accusing the state of failing to halt fraud within the program related to its management of hospice care. The move came just two weeks after Centers for Medicare and Medicaid Services Administrator Mehmet Oz announced the agency was withholding $91 million in Medicaid payments to Minnesota due to alleged fraud.
President Trump announced the expansion of TrumpRx.gov in mid-May to include approximately 600 generic medications. The website is meant to bring transparency to the most competitive cash prices of medications while encouraging users to compare those cash prices against co-pays offered by their insurance company.
President Trump also issued an executive order that establishes a pathway for eligible patients with serious mental illness to access investigational psychedelic drugs that are under Federal Drug Administration review and have met basic safety requirements.
The House Ways and Means Committee passed three health-related bills on May 21. HR 3164, introduced by Rep. Adrian Smith of Nebraska, expands seniors’ access to critical primary care services by providing Medicare reimbursement for pharmacist-administered tests and treatments for common respiratory illnesses. HR 8163, offered by Rep. Gregory Murphy of North Carolina, modernizes the Medicare Physician Fee Schedule to promote payment stability for independent doctors and patient access to care. HR 8875, sponsored by Rep. Carol Miller of West Virginia, expands patient access to home dialysis by allowing Medicare to reimburse for staff-assisted home dialysis services and renal mental health support services.
Also on May 21, the House Education and the Workforce Committee approved two healthcare-related bills. HR 7895, sponsored by Rep. Rick Allen of Georgia, prohibits kickbacks to pharmacy benefit managers (PBMs). HR 8684, introduced by Rep. Virginia Foxx of North Carolina, requires group health plans and health insurance issuers offering group health insurance coverage to pay claims submitted by hospitals only if they have policies in place to ensure accurate billing practices.
State
Oklahoma Gov. Kevin Stitt signed the following measures into law in May:
- SB 904, barring the use of public funds to provide or subsidize any gender transition procedures and prohibiting the state’s Medicaid program for reimbursing costs for any such procedures.
- SB 1447, mandating disclosures, formulary and network management, rebate pass-through, impact analyses, operational data handling, and certification requirements for PBMs contracting with the Oklahoma Employees Insurance Plan and related state plans.
- SB 1344, creating the Insulin Access and Affordability Program, which improves patient access to affordable insulin in Oklahoma and reduces prescription drug costs for consumers and payors.
Iowa Gov. Kim Reynolds signed the following measures into law in May:
- HF 2185, addressing how cost sharing may be structured for health savings accounts (HSAs) paired with qualified high-deductible health plans so that certain cost-sharing payments do not jeopardize HSA eligibility.
- HF 2635, creating and modifying standards for health carriers and utilization review organizations, focusing on prior authorization and utilization review audits.
Virginia Gov. Abigail Spanberger signed several health-related bills into law in April, including:
- SB 172, updating health insurance claims processing and provider communications by requiring carriers accept electronic attachments for claims documentation to enhance efficiency and fairness.
- SB 630, setting a cap on the rate charged by individual and small market health care plans for tobacco users of no more than 1.5 times that of non-users.
- SB 361, requiring health insurers to provide access to contraceptives, contraceptive products, and contraceptive devices without a co-pay.
- SB 626, mandating coverage for screening mammograms, postpartum services, early intervention services for children, and biologically based mental illness.
- HB 1207, establishing a comprehensive framework for paid family and medical leave benefits, eligibility, employer contributions, and program administration, with key implementation dates beginning in 2028 and 2029.
- HB 328, requiring the Bureau of Insurance to select a new essential health benefits benchmark plan for the 2029 plan year that includes, among other things, coverage for doula care services; infertility; fertility treatment and diagnosis; and hearing aids.
- HB 830, requiring a PBM use the pass-through pricing model and prohibiting a PBM from deriving income from pharmacy benefits management services provided to a pharmacist.
- HB 736, introducing new requirements for prescription drug prior authorization processes, requiring insurers accept electronic, telephonic, or facsimile submissions through standardized systems under stricter time frames.
- HB 484, which introduces several new provisions and amendments related to health insurance carrier practices and provider protections.
- SB 161/HB 625, establishing limits on cost-sharing payments for prescription drugs under certain health plans issued or renewed in Virginia on or after Jan. 1, 2028.
- HB 1284, establishing Medicaid coverage for a range of telehealth and remote monitoring services targeted at high-risk groups, including remote patient monitoring, provider-to-provider telemedicine consultations, originating site fees for emergency services, and remote ultrasounds.
- HB 1019, enhancing confidentiality protections for health records and patient data, restricting access and disclosure unless permitted by law.
Maryland Gov. Wes Moore signed the following bills into law:
- HB 1563, creating statewide requirements that prevent certain denial practices for emergency room care and expanding oversight and data reporting for emergency-department claims decisions and post-acute placement outcomes.
- SB 205/HB 280, mandating that health benefit plans provide benefits for specified mental health conditions and substance use disorders under certain circumstances and requiring carriers to explain differences in access to care.
Maine Gov. Janet Mills signed the following legislation into law:
- HP 1443/LD 2154, establishing the Health Information Technology Fund within the Maine Department of Health and Human Services to support the operation and sustainability of a statewide health information exchange.
- HP 1418/LD 2103, introducing new requirements for Maine hospitals to develop and implement comprehensive cybersecurity plans.
Kentucky Gov. Andy Beshear signed the following bills:
- HB 388, implementing medication synchronization programs within Medicaid to improve treatment adherence for chronic illnesses.
- HB 689, establishing a new Medicaid state-directed payment program that provides enhanced add-on payments to qualifying hospitals, contingent upon federal approval and specific funding sources.
Wisconsin Gov. Tony Evers signed the following measures:
- AB 699, establishing a new long-term care insurance assessment and a corresponding tax credit applicable to certain insurers and taxpayers in the state.
- SB 23, amending the state’s Medical Assistance program to extend eligibility for postpartum women up to a year after childbirth.
Washington Gov. Bob Ferguson signed the following:
- SB 5981, protecting patient access to discounted medications and health care services through Washington’s health care safety net by preventing manufacturer limitations on the 340B drug pricing program.
- HB 2384, requiring continuing care retirement communities offering life care contracts to provide an actuarial analysis prepared by a qualified actuary by July 1, 2027.
Tennessee Gov. Bill Lee signed HB 754/SB 676, requiring medical providers who perform and health insurers who cover gender transition surgeries to also perform and cover “detransition” procedures.
Minnesota Gov. Tim Walz signed SF 476, expanding coverage and modifying reimbursement rates for various home health services to enhance the accessibility and quality of care for recipients.
Nebraska Gov. Jim Pillen signed LB 967, establishing the Population Health Information Act to facilitate secure health data sharing among providers and regulators.
Alabama Gov. Kay Ivey signed SB 63, governing the use of artificial intelligence (AI) by health benefit plan providers in making coverage determinations.
Ohio Gov. Mike DeWine signed HB 229, establishing comprehensive regulatory requirements for PBMs and related healthcare entities operating within Ohio.
Utah Gov. Spencer Cox signed HB 15 into law, expanding Medicaid coverage to individuals with incomes below 133% of the federal poverty level, contingent upon federal approval, with provisions for waivers, cost controls, and targeted populations, such as chronically homeless individuals and those involved in the justice system.