Insurers are under siege heading into 2027 - Becker's Payer Issues | Payer News

By Elizabeth Casolo – From contracting battles to vertical integration scrutiny and continued prior authorization tensions, few things in healthcare are as predictable as the backlash insurance companies consistently face from lawmakers, employers and patients. Heading into 2027, those pressures are compounding. Read Full Article...

HVBA Article Summary

1. Political and public-pressure campaigns are intensifying around insurer power and structure: The article highlights renewed attention on insurer vertical integration, including lawmakers’ “Break Up Big Medicine Act” proposal and public calls to pressure or divest from large carriers. Even though the bill has not advanced, the piece frames these efforts as contributing to broader public narratives about insurers. It also notes the practical constraints on divestment given insurers’ widespread inclusion in common investment vehicles. Overall, the focus is on growing scrutiny rather than near-term policy certainty.

2. Legal and reputational headwinds are converging with ongoing consumer frustration over coverage decisions: The article points to Luigi Mangione’s upcoming state trial over the killing of UnitedHealthcare CEO Brian Thompson as a high-profile event likely to draw further negative attention toward the insurance sector. It describes the case as a flashpoint for anger about coverage denials and claims practices. The piece also notes substantial public interest in the proceedings, including fundraising for the defense and requests for expanded media access. This adds a reputational dimension to existing debates about how insurers manage access to care.

3. Rising medical costs are pushing employers, markets, and public programs into new debates and operational changes: The article describes increasing pressure on employer-sponsored coverage, including employer interest in alternatives like direct contracting and different plan designs. It also outlines proposed premium increases in ACA marketplace and small group plans for 2027, and notes Medicare Advantage insurers adjusting benefits or exiting certain plans amid funding and cost dynamics. Separately, it flags Medicaid work requirements and eligibility checks set to affect coverage stability, with potential enrollment declines and administrative challenges. Taken together, the story portrays multiple segments of the insurance system facing cost-driven strain simultaneously.

Judge refuses to dismiss Aflac data breach lawsuit

By Allison Bell – The federal judge presiding over a big data breach case involving Aflac has issued an order that lets the plaintiffs move ahead with presenting most of their arguments — including an argument that some insurance contract provide an implicit promise that the insurance company will try to protect the insured's personal information. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Most claims survive the motion-to-dismiss stage: The judge allowed the plaintiffs to continue pursuing most of their claims after Aflac asked the court to dismiss the case on procedural grounds. The order notes that, at this stage, the court must view the plaintiffs’ allegations and inferences in the light most favorable to them. As a result, the case proceeds even though the court has not yet decided whether Aflac was actually negligent.

2. Implied contractual duty to protect data remains in play: The ruling supports the possibility that certain insurance contracts may create an implied promise to reasonably protect insureds’ personal identifying information. The judge indicated this potential duty could exist independently of statutory data-security frameworks, depending on how the insurance bargain is structured. This keeps contract-based theories—alongside negligence theories—available to plaintiffs as the litigation continues.

3. HIPAA limits and a partial dismissal under California law: The court highlighted that HIPAA does not provide a private right of action for individuals to sue over alleged HIPAA violations. The judge dismissed the allegation that Aflac violated the California Consumer Privacy Act, reasoning that the breached data described in the complaint was covered by HIPAA and therefore excluded from the California statute’s scope. Other allegations, including claims tied to Georgia negligence law and Georgia contract law, were allowed to move forward.

Americans want lower health care costs. This is how they'd get it

By Ken Alltucker – On this much Democrats and Republicans agree: The cost of health insurance and health care is the biggest problem in health care today. A new survey said more than 4 in 10 adults cited the cost of health insurance as the biggest problem that needs to be fixed in the U.S. health care system. That sentiment was consistent across political affiliation, with 45% of Republicans, 44% of Democrats and 42% of independents naming health insurance as their top concern, according to the Commonwealth Fund survey of more than 25,000 adults. Read Full Article...

HVBA Article Summary

1. Out-of-pocket costs and administrative hurdles are secondary concerns: Beyond premium prices, many respondents also pointed to what they pay when they actually use care, including co-pays and deductibles for items like medical bills, lab tests, and prescription drugs. The article reports that 36% of adults identified these out-of-pocket expenses as their second biggest worry. It also notes people were less stressed about prior authorization requirements than they were about overall affordability. Taken together, the survey results suggest consumers experience cost pressures both before receiving care (premiums) and at the point of service (cost-sharing).

2. Subsidy changes are linked to ACA enrollment declines and premium anxiety: The article says more than 3 million ACA enrollees had dropped coverage as of February amid higher monthly premiums and the expiration of enhanced subsidies. It adds that when Congress did not extend those subsidies, average costs for ACA enrollees who wanted to keep coverage rose sharply, with KFF estimating a 114% increase in 2026. The survey findings described in the story indicate that people buying ACA plans or other direct coverage frequently cite cost as their biggest worry. The piece also includes the concern that unaffordable premiums could lead more people to become uninsured.

3. Workplace and Medicaid coverage face separate affordability and eligibility pressures: For employer-sponsored insurance, the story reports projections that companies expect costs to rise nearly 7% in 2026, bringing total benefit costs to about $18,500 per employee, according to Mercer. It also states that 44% of adults with workplace coverage cited the cost of those plans as their top concern, even though employers usually pay most of the premium. Separately, the article describes a Republican budget-bill provision creating Medicaid work requirements that could affect up to 18.5 million people, with the CBO projecting more than 5 million could lose coverage by 2034. These developments highlight that both affordability (premiums) and eligibility rules can influence whether people maintain coverage.

Employer health costs near 15-year high as billing pressures mount

By Steve Randall – Medical cost trends are approaching double digits for the second consecutive year with levels not seen in nearly 15 years, placing renewed pressure on US employers and the brokers advising them. The 2027 Segal Health Plan Cost Trend Survey, the firm’s 30th annual survey of managed care organizations, health insurers, pharmacy benefit managers (PBMs), and third-party administrators (TPAs), projects a median medical trend of 9.9 percent for open-access Preferred Provider Organization (PPO), Point of Service (POS), and pharmacy benefit managers (POS) plans in 2027, while prescription drug costs are projected to climb 11.5 percent. Read Full Article...

HVBA Article Summary

1. Medical costs are being pushed by multiple structural factors, not just general inflation: The article describes how consolidation among providers, including the influence of private equity ownership, can increase pricing leverage and negotiated rates. It also points to a rising burden of chronic disease and expanding utilization of therapies in areas such as neurology, inflammatory disease, and mental health. Together, these forces can make cost growth persistent even when broader economic inflation cools.

2. No Surprises Act arbitration is portrayed as a significant and underappreciated cost escalator for plan sponsors: The piece highlights how the independent dispute resolution (IDR) process can lead to out-of-network payments that far exceed typical in-network reimbursement for similar services. It reports that arbitration outcomes have often favored providers and that the process has added systemwide costs since 2022. The implication for employers is that legal protections aimed at patients can still increase financial pressure on health plans and their sponsors.

3. Pharmacy and billing dynamics are adding new complexity for employers and brokers: The article frames GLP-1 medications as a major driver of prescription drug spending as indications expand beyond diabetes into other conditions, which can enlarge the eligible population over time. It also describes how AI-assisted coding and documentation may increase recorded severity and billing intensity, potentially raising claim costs even without more care being delivered. For brokers, the discussion emphasizes the need to explain benefit changes clearly, reassess network design options, and engage employees at a population level to manage utilization and plan choices.

The VA’s Largest Community Care Administrator Has a Mental Health Problem

By Russell Lemle – For many veterans grappling with mental health issues, nothing beats sitting in the room with a therapist. Charlie Marg is one of them. His wife, Paige, testified to this last year at a Senate Committee on Veterans’ Affairs hearing examining treatment in the Community Care Network (CCN) — the VA’s backup pool of private-sector providers: “My husband has utilized telehealth before in some of his referrals to community care. Personally, he would rather choose to see somebody in person… especially when he’s talking about his mental health struggles.” Read Full Article...

HVBA Article Summary

1. Optum clinic closures may be reducing in-person mental health access within the VA’s Community Care Network: The article cites a prior investigation that traced UnitedHealth/Optum behavioral-health acquisitions from 2011–2025 and reported that Optum bought 70 entities operating hundreds of offices, then fully or partially shut down half of them. Examples described include short-notice closures and cancellations that can leave patients without clear transfer plans and potentially pushed toward virtual-only options. The author also describes contacting specific sites and being told they had participated in the CCN, suggesting potential direct impact on veterans seeking community care. The piece frames these dynamics as driven by corporate decisions rather than VA policy changes.

2. Federal oversight reports highlight delays and telehealth-heavy availability in community mental health care: The article references a VA Office of Inspector General report released “this week” that found Optum and TriWest struggling with timely access in FY2025, including referrals that did not result in an initial appointment within the expected timeframe and longer average waits when deadlines were missed. It also notes the OIG’s finding that many CCN mental health providers primarily or exclusively offer telehealth, creating bottlenecks for veterans who prefer face-to-face appointments. Separately, the article points to problems with provider directories, describing an audit in which many listed providers were not actually accepting VA patients and some offered only telehealth. The author argues these issues make it difficult for veterans and VA staff to reliably identify truly available in-person community options.

3. Quality and capacity concerns are presented as intersecting problems: limited community training requirements alongside shrinking VA staffing: The article says the VA MISSION Act emphasized “quality,” including expectations that community mental health providers meet standards comparable to the VA’s for areas like PTSD, MST, and TBI, but that the VA made training voluntary. Citing a GAO report, it describes very low completion of training modules among CCN clinicians during 2021–2023 and notes that veterans identified as suicide risks were referred to providers with no recorded suicide-prevention training. At the same time, the author reports that the VA has reduced its own mental health workforce since January 2025 while demand continues to rise, and that community care referrals have increased over recent years. The piece concludes that policy choices by the VA and Congress—along with contractor behavior—are contributing to gaps in timely, in-person, and evidence-based care.

US FDA approves Lantheus' brain-imaging agent for Alzheimer's assessment

By Kunal Das and Puyaan Singh – The U.S. Food and Drug Administration has approved a radioactive agent from Lantheus Holdings (LNTH.O), for use in brain scans to help assess patients for Alzheimer's disease, ‌the company said on Friday. The agent, branded as Tauklarify, is injected before a positron emission tomography, or PET, scan. It makes abnormal deposits of tau proteins linked to Alzheimer’s visible in ​images of the brain in adults with cognitive impairment who are being ​assessed for the disease. Read Full Article...

HVBA Article Summary

1. FDA Approval Expands Tau Imaging Options: Lantheus received approval for Tauklarify, a PET imaging agent designed to help identify tau pathology associated with Alzheimer’s disease. The approval was supported by two studies in which independent readers evaluated scans from more than 500 participants. Lantheus cautioned that a positive scan does not definitively confirm tau pathology, while a negative scan does not completely rule it out.

2. Tau Provides Insight Into Alzheimer’s Progression: Alzheimer’s is associated with abnormal deposits of beta-amyloid and tau proteins, with tau levels and distribution more closely linked to worsening memory and cognitive function. More than 7 million Americans currently have Alzheimer’s, and the population age 65 and older with the disease could surpass 13 million by 2050. Despite its potential diagnostic value, tau imaging has limited clinical use because there is currently no approved Alzheimer’s treatment specifically targeting tau.

3. Tauklarify Enters a Small, Established Imaging Market: Eli Lilly’s Tauvid, approved in 2020, currently dominates a U.S. tau-imaging market estimated at less than $100 million annually. B. Riley Securities analyst Yuan Zhi projects Tauklarify sales will remain below $50 million annually through 2030. The approval also comes shortly after Curium agreed to acquire Lantheus for up to $8 billion, with the transaction expected to close in the first half of 2027.

Lilly files six lawsuits in bid to shut down ‘black market’ for retatrutide

By Kristin Jensen – Lilly is seeking the help of courts, regulators and law enforcement agencies at a time when top U.S. health official Robert F. Kennedy Jr. appears inclined to give a freer rein to unreviewed substances in the medical marketplace. In July, an FDA advisory panel endorsed broader use of six peptides for various ailments without substantial evidence of their safety and effectiveness. Lilly’s fight has also been made more difficult by the increasing use of pharmacies and companies that offer compounded versions of obesity medicines. They rose to prominence in the early days of the GLP-1 drug explosion, when Lilly and rival Novo Nordisk couldn’t keep up with demand, and have continued to steal market share even after the FDA proclaimed the shortage over and told them to stop sales. Read Full Article...

HVBA Article Summary

1. Legal escalation targeting alleged sellers of retatrutide: Eli Lilly says it has filed six new lawsuits aimed at entities it believes are involved in selling versions of retatrutide before the drug is approved. The company frames the suits as part of a broader effort to curb online and clinic-based access to substances marketed as retatrutide. The dispute centers on products Lilly describes as untested and sold outside standard regulatory pathways.

2. Demand for an unapproved drug is driving a broad set of supply channels: The article describes consumers seeking retatrutide through online merchants, clinics, compounders, and foreign companies that claim to offer the drug. Lilly argues these products may be fake, impure, or incorrectly dosed, and therefore potentially dangerous. The story also notes that some sellers present themselves as legitimate providers or advertise “research use only” positioning.

3. Enforcement efforts span regulators, law enforcement, and online monitoring: Lilly says it has referred more than 200 people and entities to regulators, professional licensing boards, and law-enforcement officials related to the black-market trade. It also reports flagging more than 14,000 websites, ads, social media posts, and product listings across over 100 countries. Separately, reporting cited in the piece indicates that clinics and compounding pharmacies have also been advertising retatrutide, not just anonymous online vendors.