PLANSPONSOR Roadmap: Health Benefit Fiduciaries—PBM Fact vs. Fiction

By Emily Boyle – Health benefit plan sponsors can fulfill their fiduciary duties with confidence by negotiating favorable contract terms with pharmacy benefit managers, getting audit performance guarantees from their providers and considering sourcing their prescription drug plan from beyond the “big three” PBMs, according to speakers at the third and final session of the 2026 PLANSPONSOR Roadmap: Health Benefit Fiduciary Duties livestream series. “For HR benefits professionals, few responsibilities can feel more scrutinized than managing health benefits in an environment of relentless cost pressure,” said Amy Resnick, the event’s introductory speaker and executive editor of PLANSPONSOR digital. “The trends don’t just impact budgets—they directly impact employee affordability, workplace trust and the decisions fiduciaries are expected to defend.”Read Full Article...

HVBA Article Summary

1. Rising Employer Health Care Costs: Employer-sponsored health benefit costs are projected to rise by 6.7% in 2026 after planned cost-saving measures, compared to more than 9% before adjustments. This represents a significant increase from the roughly 3% annual growth seen in the decade leading up to 2023. The upward trend is placing growing pressure on business operations, with many CFOs ranking health care expenses among their top concerns.

2. PBM Market Concentration and Regulatory Changes: The prescription drug market is dominated by three major pharmacy benefit managers—CVS Caremark, OptumRx, and Express Scripts—which collectively handle about 80% of claims. These firms have faced criticism for pricing practices such as rebate retention and spread pricing that can limit cost transparency. New federal legislation requires greater disclosure and mandates rebate pass-throughs, though most provisions will not take effect until around 2029.

3. Emerging Alternatives and Fiduciary Challenges: Mid-market PBMs have entered the market with different pricing and transparency models, offering potential alternatives to larger providers. However, these options are not universally effective, and plan sponsors must carefully evaluate whether switching providers aligns with their financial and fiduciary responsibilities. Limited fee transparency and complex pricing structures continue to make it difficult for fiduciaries to assess cost reasonableness and fully manage health plan expenses.

Rand Paul lobbies RFK Jr. for support for association health plans

By Allison Bell – Sen. Rand Paul tried to persuade Robert F. Kennedy Jr., the secretary of the U.S. Department of Health and Human Services, to talk about association health plans earlier this week. Kennedy steered the conversation toward health savings accounts and never used the terms "association health plan" or AHP himself. The exchange occurred during the same Senate Health, Education, Labor and Pensions Committee hearing where Kennedy talked about subjects such as maternal health disparities. The committee organized the hearing to talk to Kennedy about the HHS budget for the federal government's 2027 fiscal year, which starts Oct. 1. Most of the conversation focused on government health programs and public health programs. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Sen. Rand Paul's Advocacy for AHPs: Senator Rand Paul has consistently advocated for making it easier for small employers and individuals to join association health plans (AHPs) as a way to increase bargaining power and potentially lower health coverage costs. During the Senate hearing, he emphasized the benefits of collective negotiation through associations or co-ops, likening it to large-scale buyers like Costco. Paul argued that current regulations restrict AHP participation to groups with specific occupational ties, limiting broader access.

2. Focus Shift to Health Savings Accounts: Despite Paul's efforts to discuss AHPs, HHS Secretary Robert F. Kennedy Jr. redirected the conversation to health savings accounts (HSAs), highlighting their potential to empower consumers and reduce insurance industry profits. Kennedy did not address AHPs directly, instead suggesting that expanding HSA access could drive market-based cost reductions. This response indicates a possible policy preference within the current administration for HSAs over alternative group coverage models like AHPs.

3. Debate Over AHPs' Impact and Regulation: The article outlines the ongoing debate surrounding AHPs, with supporters claiming that large, multistate AHPs can leverage size and federal regulations to offer comprehensive, affordable coverage similar to large employers. Critics, however, warn that expanding AHPs could destabilize the small-group insurance market and lead to adverse selection. Proposed legislation aims to address these concerns by including protections against medical underwriting and plan insolvency, but the future of AHP expansion remains uncertain amid shifting policy priorities.

AMA urges lawmakers to implement safeguards on AI chatbots

By Emily Olsen – A growing number of Americans are turning to AI chatbots for health information. Nearly 30% of people report they’ve used the tools for advice on their physical health in the past year, while 1 in 6 said they had used AI for mental health, according to a poll published last month by health policy research group the KFF. Proponents argue the tools could help Americans navigate the nation’s complex healthcare ecosystem and find quick answers to questions — a particular challenge in behavioral healthcare, where many communities face a shortage of mental health professionals. Read Full Article...

HVBA Article Summary

1. AMA's Call for Regulation: The American Medical Association (AMA) has formally requested that Congress establish regulatory safeguards for AI chatbots used in mental health care. The AMA argues that while these tools can increase access to support, the absence of oversight could lead to significant risks for vulnerable users. Their recommendations include prohibiting chatbots from diagnosing or treating mental health conditions unless reviewed by the FDA as medical devices.

2. Risks and Privacy Concerns: The AMA highlights several dangers associated with mental health chatbots, such as privacy breaches, emotional dependency, and the potential for chatbots to inadvertently encourage self-harm. The organization points to real-world incidents where AI failed to direct users to appropriate help or even appeared to promote harmful behaviors. To address these issues, the AMA suggests requirements for transparency, ongoing safety monitoring, and clear disclosure that users are interacting with AI rather than a human.

3. State and Federal Regulatory Landscape: While the federal government has so far taken a relatively hands-off approach to AI regulation, some states have enacted laws specifically targeting mental health chatbots. For example, Illinois has banned AI for therapeutic decision-making, and California requires monitoring for suicidal ideation in chatbot interactions. The AMA's advocacy reflects a broader movement toward more comprehensive oversight as AI becomes increasingly integrated into healthcare.

LTC coverage emerging as a necessary consideration

By Charlotte Santa Cruz – For nearly a decade, the conversation surrounding the investment in long-term care (LTC) insurance has emerged as a pressing concern for many individuals and families. Navigating the individual market to find affordable and accessible coverage can be overwhelming, particularly for those with pre-existing health conditions. Fortunately, there are now remarkable options available. As standalone LTC plans have become increasingly scarce and costly, the relatively new worksite hybrid life with long-term care insurance has emerged as an attractive alternative. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Hybrid Life and LTC Policies Offer Dual Protection: Worksite hybrid life insurance policies that include long-term care (LTC) benefits are becoming a popular alternative to traditional standalone LTC plans. These hybrid policies provide both a death benefit and LTC coverage, ensuring that policyholders and their beneficiaries are protected regardless of whether LTC benefits are used. This structure addresses concerns about losing value if LTC is never needed, offering a no-loss scenario for policyholders.

2. Personal Experiences Highlight the Importance of LTC Coverage: The author shares personal stories involving both an accident and a family member’s dementia diagnosis to illustrate the unpredictable need for long-term care. These experiences underscore the financial and emotional challenges that can arise unexpectedly, emphasizing the necessity of planning ahead. The narrative demonstrates that LTC insurance is relevant for individuals at any stage of life, not just the elderly or those with known health issues.

3. Accessibility and Affordability Are Key Advantages: Hybrid life-LTC products are designed to be more accessible and affordable than traditional LTC insurance, often without imposing strict health requirements. The benefits structure typically allows for a percentage of the death benefit to be used for LTC needs, with the possibility of restoring the full benefit for beneficiaries. Additionally, these policies may offer favorable tax treatment, making them an attractive option for both employees and employers seeking comprehensive coverage solutions.

Health insurers used hidden online tracking tools, lawsuits allege

By Susan Rupe – In less than a year, four claims filed against major health insurers allege the companies used hidden tracking tools on their websites to record users’ most sensitive health queries in real time, then transmitted that data to third-party firms. “These practices are, as alleged, we believe, quite widespread and concerning,” said Andrew Schlichter, co-managing partner at the law firm Schlichter Bogard, which filed each of the four class-action lawsuits in federal court after investigating claims of data harvesting and sharing. Read Full Article...

HVBA Article Summary

1. Allegations of Widespread Data Tracking: Four major health insurers—Humana, Cigna, Elevance Health, and Blue Cross Blue Shield of Michigan—are facing lawsuits alleging they used hidden tracking tools on their websites to monitor users’ health-related searches. The lawsuits claim that these tools captured sensitive information such as search terms, typed content, and interactions within secure portals. Plaintiffs argue that this data was then transmitted to third-party advertising and analytics firms without proper user consent.

2. Potential Legal Violations and Privacy Concerns: The lawsuits assert that the insurers’ actions may have violated federal and state wiretap laws, as well as health privacy regulations like HIPAA and CMS guidance. Plaintiffs allege that privacy notices and consent mechanisms were either misleading or ineffective, with some sites displaying assurances that no data would be shared while tracking continued in the background. These practices have raised significant concerns about the security and confidentiality of individuals’ health information.

3. Implications for Consumer Trust and Industry Practices: The cases highlight growing unease among consumers regarding how their personal health data is handled by insurers and associated third parties. Plaintiffs and their attorneys emphasize the importance of trust in the insurer-insured relationship, especially when dealing with sensitive health matters. The outcomes of these lawsuits could prompt changes in how health insurers use online tracking technologies and communicate privacy practices to users.

Evidence Grows for Weight Loss Reducing Cancer Risk

By Nancy A. Melville – Mounting evidence that weight loss can reduce cancer risk is reinforcing the established causal link between obesity and cancer, prompting experts to call for greater awareness of an association that remains underestimated. "Our study serves as a call for action and a strong public health message to health care stakeholders to intensify efforts and resources to treat obesity as a chronic disease to help reduce the risk of developing cancer," wrote the authors of one of the latest studies, published in the journal Obesity, which highlighted reduced cancer risk with nonsurgical weight loss. Read Full Article...

HVBA Article Summary

1. Weight Loss and Cancer Risk Reduction: Recent large-scale studies have shown that even modest weight loss in individuals with obesity is associated with a lower risk of developing various types of cancer. This association holds true for both surgical and nonsurgical weight loss, though the strongest evidence comes from bariatric surgery. The findings reinforce the importance of treating obesity as a chronic disease to help reduce cancer incidence.

2. Role of GLP-1 Receptor Agonists and Mechanisms: Emerging research suggests that GLP-1 receptor agonists, medications used for weight loss and diabetes, may also contribute to reduced cancer risk. However, it remains unclear whether the benefit is due solely to weight loss or if these medications have independent protective effects against cancer. Further prospective studies are needed to clarify the mechanisms and long-term impact of these therapies on cancer prevention.

3. Need for Greater Awareness and Improved Risk Assessment: Despite growing evidence, the link between obesity and cancer risk remains underrecognized among healthcare professionals and the public. Experts advocate for enhanced education, updated clinical guidelines, and the adoption of new frameworks like the "PLUS" model to better assess and manage obesity-related cancer risk. Addressing this gap could lead to more proactive prevention strategies and a significant reduction in cancer burden globally.

Health care spending returns to pre-pandemic trajectory as costs climb

By Joel Kranc – Health care spending in the United States is a key driver of the nation's growing debt and has again increased — reaching $5.3 trillion in 2024. Data from the National Health Expenditure Accounts released by the Centers for Medicare and Medicaid Services (CMS) show why spending is on the rise and how it will impact the economy. Here are five reasons as to why the spending continues to climb: 1. Health care spending increased by 7.2% in 2024, surpassing $5 trillion for the first time. Total spending on health care (both private and public) increased by 7.2% in 2024 after a 7.4% increase in 2023. Read Full Article...

HVBA Article Summary

1. Spending Growth Outpaces Inflation: Health care spending per capita rose more rapidly than the general inflation rate between 2023 and 2024. This trend suggests that health care costs are becoming a larger burden for individuals and families, as their expenses grow faster than other goods and services. The increase is partly attributed to higher utilization rates and the lagging effect of pre-established payment contracts in the health care sector.

2. Public Payers’ Expanding Role: Government programs such as Medicare, Medicaid, CHIP, the VA, and the Department of Defense now account for a significant portion of national health expenditures. The share of health care spending covered by public payers has grown substantially since 1970, reflecting both demographic changes and policy shifts. This expansion underscores the increasing reliance on public funding to support the health care needs of the U.S. population.

3. Rise in Uninsured Population: For the first time since 2019, the number of uninsured Americans increased, reversing previous declines. This change is linked to the expiration of pandemic-era policies that prevented states from disenrolling Medicaid beneficiaries, resulting in a notable drop in Medicaid enrollment. The increase in uninsured individuals may have implications for access to care and financial stability for those affected.

Restrictions on obesity drug coverage force patients to pivot

By Sydney Lupkin – For Meghan Lena, a special ed teacher in Massachusetts, the letter she got last spring from the company that manages her drug benefits really hurt. CVS Caremark said it was dropping Eli Lilly's blockbuster obesity drug Zepbound from its coverage in July. "I was devastated," she says. She'd been able to get Zepbound for a $30 monthly copay and had lost 50 pounds in a year. The drug helped her focus on being a new mom and gaining strength at the gym, she says, not just counting calories burned. She feared that if she stopped taking it, all her progress would vanish. Read Full Article...

HVBA Article Summary

1. Insurance Coverage Declines and Access Restrictions: Coverage for GLP-1 medications such as Wegovy and Zepboundhas become more limited, with millions of individuals losing access between 2025 and 2026. Among those who still have coverage, most face restrictions like prior authorization requirements or elevated BMI thresholds. These changes have made consistent and equitable access to obesity treatments more difficult for many patients.

2. Rising Costs Influence Insurance and Patient Decisions: High drug prices are a central factor shaping employer and insurer coverage policies, leading to formulary changes and reduced benefits. Patients often encounter substantial out-of-pocket costs, sometimes making it more economical to pay cash rather than use insurance. Insurers and pharmacy benefit managers maintain that manufacturer pricing remains a key barrier to broader and more affordable access.

3. Patients Turn to Alternative Treatment Options: Due to coverage instability, some patients seek alternatives such as compounded medications to manage costs. While these options may provide short-term affordability, they are not FDA-approved and carry uncertainty regarding long-term availability and oversight. This environment leaves patients navigating fluctuating coverage, financial pressures, and evolving treatment pathways.