The Ledger

60 billion dollars: that is the federal Medicaid hospital funding nationwide that a new government tally says already exceeds Congress’s incoming payment limits, and Texas hospitals are living the consequences first. The Kaiser Family Foundation (KFF) found in an August 14, 2026 analysis that at least 37 states carry a combined 60 billion dollars in federal spending on Medicaid state directed payments (SDPs) to hospitals that exceeds the new caps set by the 2025 reconciliation law, known as the One Big Beautiful Bill Act; the law replaces payment ceilings tied to average commercial insurance rates with caps of 100 percent of Medicare rates in states that expanded Medicaid and 110 percent in states, like Texas, that did not, phased in starting January 2028. Texas carries the fourth-largest exposure at 3.5 billion dollars, behind California’s 7.4 billion dollars, Illinois’s 4.0 billion dollars and Kentucky’s 3.9 billion dollars, and ahead of North Carolina, Louisiana, Arizona and Michigan, which each face reductions above 2.5 billion dollars. The cut is not waiting for 2028 in Texas: the Centers for Medicare and Medicaid Services (CMS) has withheld approval of roughly 9.8 billion dollars in Texas Medicaid directed-payment programs for the state fiscal year that began September 1, and the Texas Hospital Association says the impasse is already costing hospitals 27 million dollars a day, with association president John Hawkins warning September 8 that the state is “bracing for a crisis that will crack the Texas healthcare safety net.” A Bond Buyer review of state and industry data published the same day found 84 of Texas’s 153 rural inpatient hospitals now financially at risk and 27 facing immediate closure risk, against just 1.4 billion dollars Texas expects over five years from the federal Rural Health Transformation Program meant to cushion the broader Medicaid cuts. Confidence: High on the KFF multistate figures, which this run reviewed directly. Medium on the Texas rural-hospital closure count, drawn from Bond Buyer’s synthesis of third-party data rather than a primary report this run opened directly. Sources: At Least 37 States Have Medicaid State Directed Payments for Hospital Services That Could Be Reduced by the 2025 Reconciliation Law Limits, KFF, Texas hospitals’ financial headwinds include Medicaid funding losses, closure risks, Bond Buyer.

1.1 million: that is how many fewer Medicare Advantage members UnitedHealth Group has told Wall Street to expect by the end of this year, weeks before federal rules require insurers to tell the affected members themselves. UnitedHealth Group disclosed on 2026 earnings calls that it will exit Medicare Advantage (MA) plans in 109 US counties, part of an expected 1.1 million-member enrollment decline for the year; Humana Chief Financial Officer Celeste Mellet told analysts on the company’s July 29, 2026 earnings call that Humana will exit plans covering 600,000 members in 2027, aiming to “remove or cut off the lower tail of profitability and returns,” while Elevance Health reported Medicare Advantage membership down 15.9 percent year over year in the second quarter and Centene Chief Executive Officer Sarah London described a simplified Medicare Advantage footprint centered on dual-eligible members. Insurers submitted their 2027 plan bids to the Centers for Medicare and Medicaid Services (CMS) in June and have spent the summer explaining the resulting exits to investors on earnings calls, but the federal non-renewal notices that tell members their own plan is ending are not due until October 2, leaving members as little as 66 days before Open Enrollment closes December 7 and the plans terminate December 31; those who do not act fall into a Special Enrollment Period running December 8 through February 28, 2027. For readers tracking MA-exposed insurer stocks, the gap between when Wall Street learned which plans are dying and when members will is itself a data point on how much lead time the market gets on 2027 enrollment disruption. Confidence: High on the company-specific figures, drawn from earnings-call statements reported directly by trade press. Medium on the aggregate framing and regulatory deadline dates, drawn from a single secondary source’s compilation. Sources: Humana to exit Medicare Advantage plans covering 600,000 members in 2027, Becker’s Payer Issues, UnitedHealth to exit Medicare Advantage plans in 109 US counties, HealthLeaders Media, Insurers Have Already Told Wall Street Which Advantage Plans Die on December 31, 24/7 Wall St..

800 million dollars: that is the price tag, including milestones, on a drugmaker’s push into a rare inherited blindness before any competitor reaches the market. Tarsus Pharmaceuticals completed its acquisition of privately held Alkeus Pharmaceuticals on September 4, 2026, paying 450 million dollars upfront (270 million dollars in cash and 180 million dollars in Tarsus stock) plus up to 350 million dollars more tied to regulatory and commercial milestones, for worldwide rights to gildeuretinol (ALK-001), a once-daily oral therapy for Stargardt disease that carries US Food and Drug Administration (FDA) Breakthrough Therapy, Orphan Drug, Fast Track and Rare Pediatric Disease designations. The deal, first announced August 6, 2026 and completed after customary closing conditions and Hart-Scott-Rodino antitrust review, gives Tarsus, best known for its eyelid-mite treatment Xdemvy, a second major eye-care franchise while gildeuretinol’s pivotal NORTHSTAR Phase 3 trial continues toward topline data expected in 2029; Stargardt disease currently has no approved treatment. Confidence: High. This run reviewed Tarsus’s own closing announcement directly. Sources: Tarsus Pharmaceuticals Completes Acquisition of Alkeus Pharmaceuticals, Expanding Leadership in Eye Care, BioSpace, Tarsus pays $450M for Alkeus and its phase 3-stage retinal disease drug, Fierce Biotech.

91 percent: that is the share of a small Arkansas and Oklahoma nursing-home operator’s shareholders who cashed out this week as a New York investment group took the company private. Black Pearl Equities completed its tender offer for all outstanding shares of Selectis Health, Inc. on September 1, 2026, paying 5.75 dollars per share in cash after approximately 90.93 percent of shares, 2,789,027 shares, were validly tendered by the offer’s August 31 expiration; Selectis, which trades over the counter and owns eight skilled nursing, assisted living and independent living properties across Arkansas and Oklahoma, will see its remaining untendered shares converted into the right to receive the same 5.75 dollars per share. The deal is small by dollar volume, but it is another data point in a pattern this run has tracked all year: small-cap, publicly traded post-acute operators going private into the hands of specialized real estate and operating investors rather than staying public through a difficult reimbursement environment. Confidence: High. This run reviewed the companies’ own SEC filings and press release directly. Sources: Black Pearl Completes Tender Offer for All Outstanding Shares of Selectis Health, Inc., PR Newswire, Selectis Health, Inc. Form SC TO-T/A, SEC EDGAR.

THE DEAL SHEET

Target	Acquirer/Investor	Vertical	Value	Source
Alkeus Pharmaceuticals	Tarsus Pharmaceuticals	Ophthalmology biopharma, rare disease	Up to $800 million ($450M upfront, up to $350M in milestones); completed September 4, 2026	BioSpace
Selectis Health, Inc.	Black Pearl Equities	Post-acute and senior housing (skilled nursing, assisted/independent living)	$5.75 per share cash; approximately 90.93% of shares tendered; completed September 1, 2026	PR Newswire
Healthcare IT Leaders, LLC	Kyndryl	Healthcare IT services, AI modernization	Undisclosed; announced August 10, 2026	Kyndryl Investor Relations
Homeward Health	Cityblock Health (all-stock, alongside a $116 million Series E)	Rural and urban integrated Medicaid care delivery	Undisclosed stock-for-stock deal; $116 million Series E led by General Catalyst; announced August 20, 2026	Fierce Healthcare

This run’s scan of FTC and DOJ merger actions and state transaction-review dockets found no new healthcare antitrust complaints or consent orders in the last 24 to 48 hours. A frontier check on nonprofit hospital tax-exemption scrutiny, a Ledger branch not touched in the last three issues, found no new floor action on the Tax Exempt Hospital Transparency Act (H.R. 9504) since the House Ways and Means Committee advanced it July 1; the bill remains stalled pending further House action. An open-ended scan surfaced the Medicare Advantage insurer-disclosure story, covered above, as the window’s most consequential business signal outside the Deal Sheet.