New Study: Even Subsidized Job-Based Health Insurance Has Become Unaffordable

By Wendell Potter - A new study from the Commonwealth Fund confirms a pain that millions of American workers already know: having employer-based health insurance  (or job-based, as the study calls it) is no guarantee that workers are protected from financial ruin if they get sick or injured. Read Full Article… 

HVBA Article Summary

1. Rising Costs of Employer-Sponsored Insurance: The Commonwealth Fund study reveals that premiums, deductibles, and out-of-pocket expenses for employer-sponsored insurance (ESI) are taking an increasing share of low- and middle-income workers' paychecks, with nearly a quarter of U.S. families spending over 10% of their income just on premiums and deductibles in 2023.

2. Impact of High-Deductible Plans: Insurers, such as Cigna, have shifted more workers to high-deductible plans, which are more profitable for companies but create greater financial burdens on patients. These plans often leave workers underinsured, with significant out-of-pocket costs for healthcare services that are not fully covered.

3. Policy Recommendations for Reform: The study calls for several policy changes, including expanding subsidies for workers with unaffordable job-based plans through the ACA marketplace, educating low-income workers about Medicaid options, and empowering states to regulate premiums and cost-sharing in their own health insurance markets.

CMS finalizes 5.06% Medicare Advantage benchmark increase

By Noah Tong - The Centers for Medicare & Medicaid Services (CMS) finalized an increase of the average benchmark payments to Medicare Advantage (MA) plans by 5.06%, or $25 billion, on Monday. It is nearly a three-percentage-point increase over the advance notice proposed in the waning days of the Biden administration and will be seen as favorable to payers. The CMS said this is due to the effective growth rate increase from 5.93% to 9.04% in the rate announcement. Read Full Article… 

HVBA Article Summary

1. Payment Rate Adjustments and Market Reaction: CMS updated Medicare Advantage (MA) payment rates by incorporating additional fee-for-service data, resulting in a modest payment decrease of about 0.25%. Despite this, the market responded positively due to the higher-than-expected payment rates, with stocks of major insurers like UnitedHealth, Humana, and CVS Health rising sharply in after-hours trading.

2. Risk Adjustment Model and Policy Changes: CMS confirmed it will complete the transition to the new MA risk adjustment model and continue excluding medical education costs from growth rate calculations—moves that drew mixed reactions. While groups like ACHP supported the transition, many insurers had pushed for a pause. The new rate also introduces a rebranded health equity index, Excellent Health Outcomes for All (EHO4all), targeting vulnerable populations starting in 2027.

3. Provider Concerns and Policy Tradeoffs: Physicians and healthcare providers criticized the payment updates for favoring insurers while provider reimbursement cuts remain unaddressed. Meanwhile, CMS declined to advance several Biden-supported policies, including Medicare coverage for anti-obesity drugs, but did finalize rules on prior authorization reforms and benefits for the chronically ill in the 2026 MA and Part D final rule.

FTC Chair Ferguson changes course on recusal from PBM insulin case

By Paige Minemyer - Federal Trade Commission Chair Andrew Ferguson has reversed course on his decision to recuse himself from the agency's legal battle with pharmacy benefit managers. Ferguson said in a statement posted to X late Thursday that he previously made the choice to step back from the proceedings because he had advised Virginia's attorney general as to whether to file an amicus brief in a class action case against PBMs during his time as the state's solicitor general. Read Full Article…

HVBA Article Summary

1. FTC Proceedings Paused Due to Commissioner Vacancies: The FTC has issued a 105-day stay in its antitrust case against major pharmacy benefit managers (PBMs) due to the lack of available commissioners. The stay follows the resignation of former Chair Lina Khan and the firing of Democratic Commissioners Alvaro Bedoya and Rebecca Kelly Slaughter by President Trump. The two remaining commissioners, Republicans Andrew Ferguson and Melissa Holyoak, had recused themselves from the case, though Ferguson has since reversed his recusal.

2. Case Timeline and Uncertainty: With Ferguson’s decision to rejoin the case, the future timeline remains uncertain. If the current stay holds, an evidentiary hearing is expected 225 days after the stay is lifted. The FTC's ability to move forward hinges on the resolution of leadership gaps, as Bedoya and Slaughter are suing to regain their positions.

3. Antitrust Case Against PBMs: The FTC’s lawsuit, filed in September, targets the “Big Three” PBMs—CVS Caremark, Optum Rx, and Express Scripts—alleging anticompetitive practices that inflate insulin prices. The PBMs have countersued, claiming the FTC is overreaching and arguing that pharmaceutical companies are to blame for high drug prices. The case stems from a lengthy FTC investigation into PBM pricing, vertical integration, and ties to group purchasing organizations.

$30 billion in medical debt wiped out for millions

By Noam N. Levey - Underscoring the massive scale of America’s medical debt problem, a New York-based nonprofit has struck a deal to pay off old medical bills for an estimated 20 million people. Undue Medical Debt, which buys patient debt, is retiring $30 billion worth of unpaid bills in a single transaction with Pendrick Capital Partners, a Virginia-based debt trading company. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Massive Debt Relief Effort Provides Temporary Relief but Not a Systemic Solution: Undue Medical Debt’s $36 million deal to acquire and erase medical debts previously owned by Pendrick will protect millions of Americans from debt collectors, but advocates warn it’s a short-term fix that doesn’t address the root causes of the U.S. medical debt crisis affecting nearly 100 million people.

2. Debt Relief Highlights Broader Healthcare Financing Failures: The nonprofit’s approach, while impactful, underscores the unsustainable nature of the current healthcare financing system — one in which patients routinely borrow billions to afford care and even those helped by debt relief often carry additional burdens not covered by such programs.

3. Calls for National Policy Action as Local Solutions Reach Their Limits: While state and local governments are working with Undue Medical Debt and improving financial aid programs, leaders and advocates stress that federal action is crucial. They point to stalled or reversed national regulations on credit reporting and a lack of Medicaid expansion in states like Texas and Florida as significant barriers to lasting reform.

Five Agencies Being Merged Into AHA: Here's What They Do

By Jennifer Henderson - The restructuring plans announced by HHS last week included folding five offices into one entity: the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), the National Institute for Occupational Safety and Health (NIOSH), the Agency for Toxic Substances and Disease Registry (ATSDR), and the Office of the Assistant Secretary for Health (OASH). Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Creation of the Administration for a Healthy America (AHA): The new AHA, supported by the U.S. Surgeon General and a dedicated policy team, will centralize and coordinate chronic care and disease prevention programs, with a focus on serving low-income Americans. It will encompass divisions such as primary care, maternal and child health, mental health, HIV/AIDS, environmental health, and workforce development.

2. Concerns Over Workforce Cuts and Service Impact: While experts agree that consolidation could reduce redundancy, there is growing concern about the rapid pace of workforce reductions and the potential negative impact on critical services, particularly in addiction treatment and occupational health. Leaders like former CMS Administrator Tom Scully and the American Society of Addiction Medicine have urged more cautious implementation.

3. Significant Changes to Key Agencies: The restructuring merges programs and functions from major health entities, including SAMHSA, HRSA, NIOSH, ATSDR, and OASH. These agencies previously handled vital functions like behavioral health grants, drug pricing support, workplace safety research, environmental hazard response, and public health initiatives—raising questions about continuity of expertise and funding in the transition to AHA.

29 million Americans can't afford health care, highest number since 2021

By Alan Goforth - More than 1 in 10 American adults is unable to afford or access quality health care, according to the recent West Health-Gallup Healthcare Indices Study. This is the highest number since 2021 and is equivalent to 29 million people. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Disparities Deepen Among Racial and Economic Groups: Cost desperation has surged most significantly among Hispanic adults (up 8 points to 18%), Black adults (up 5 points to 14%), and low-income households (up 11 points to 25%), while there has been no notable change for white or higher-income adults—widening already pronounced disparities in health care access.

2. Low-Income Households Face Intensifying Struggles: Households earning under $48,000 annually report major increases in difficulty affording health care, with cost desperation jumping 11 points to 64% among those earning under $24,000, and 12 points to 57% for those earning between $24,000 and $48,000.

3. Widespread Financial Strain and Growing Insecurity: Only about half of Americans are now considered cost secure, while nearly 4 in 10 are cost insecure and 12% report borrowing a total of $74 billion last year to cover health expenses—highlighting the broadening economic pressure tied to health care affordability.

'The AI will see you now'

By Paul Carroll - My introduction to psychology came in high school when my best friend's mother earned a PhD in the field and began writing a syndicated newspaper column that led to a talk show on Pittsburgh radio. Sam snickered at the notion that anyone would take advice from his mom but wound up on her show as a reluctant guest some years later. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. AI Therapy Shows Real Promise—but with Caution: A recent study found that the AI “Therabot” delivered therapy-like results with significant reductions in depression and anxiety, rivaling traditional human therapy in half the time. However, real-world deployment carries serious risks, especially when AI is mistaken for licensed professionals—highlighted by tragic cases involving teens and chatbots.

2. Customer Service Bots Are Learning From AI Therapy’s Success: The insurance industry is watching closely. Just like Therabot was trained to be helpful and human-like, insurers are fine-tuning chatbots to be more empathetic, useful, and jargon-free. Allstate’s AI is already outperforming some agents in tone and clarity, especially in high-volume communications like claim updates.

3. The Big Wins: Frequency, Reach, and Consistent Tone: Bots can operate 24/7, scale effortlessly, and never get tired or irritated. They ensure consistent messaging and tone—something even the best human teams struggle with. This kind of reliability and availability is transforming both mental health support and customer service alike.