Federal judge pauses ACA rule that would have ended coverage for 1.8M people

By Alan Goforth – A federal district court judge in Maryland temporarily paused several provisions of the Trump administration’s regulatory changes to the Affordable Care Act that were set to take effect on Monday. U.S. District Judge Brendan Hurson on Friday ruled in favor of a challenge from the city of Chicago; the Baltimore mayor and city council; and public health advocates. The plaintiffs alleged that numerous people would lose health insurance coverage if the changes were implemented. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Judge Halts Multiple ACA Provisions: U.S. District Judge Brendan Hurson stayed seven provisions of the CMS rule that would have taken effect immediately, pausing their implementation. The stayed provisions include a $5 premium penalty for automatic reenrollment, disqualification for failing to reconcile tax credits, elimination of guaranteed coverage for late premium payments, higher income verification standards when exchanges find tax-data inconsistencies, and stricter eligibility checks before special enrollment periods. Plaintiffs argued these provisions would cause people to lose coverage, while regulators had said the changes were intended to combat fraud and abuse.

2. Some CMS Changes Still Allowed to Proceed: Hurson allowed CMS’ change to its methodology for calculating premium adjustments to go forward, as well as the elimination of a 60-day window for enrollees to resolve income-data inconsistencies. Those allowed changes may affect how premiums are adjusted and how quickly enrollees must address verification issues. The overall legal challenge remains ongoing and the court’s stay pauses the other policies until the case is resolved, which is expected to take months.

3. Projected Impact and Responses: In his ruling Hurson wrote that eliminating coverage for an estimated 1.8 million people would raise costs for the insured and decrease quality of care for those newly uninsured. Dr. Christine Petrin of Doctors for America praised the decision as protecting patients from losing coverage, higher costs and denied benefits. The Department of Health and Human Services declined to comment on pending litigation, and 20 Democratic state attorneys general have filed a similar challenge in Massachusetts.

AM Best downgrades health insurers’ outlook to negative

By Jakob Emerson - AM Best has downgraded its outlook for the health insurance sector from stable to negative, citing escalating medical costs and increased utilization across government, commercial and ACA plans. The credit rating agency noted higher utilization of specialty drugs, increased physician visits, more inpatient admissions and a surge in behavioral health claims. The coding intensity of medical services has also increased, according to an Aug. 25 news release. Read Full Article…

HVBA Article Summary

1. Rising Healthcare Utilization and Costs Across All Segments: Health insurers across all major segments—including Medicare Advantage, Medicaid, the commercial group market, and the ACA marketplace—are reporting elevated levels of healthcare utilization and medical expenses. This includes a notable uptick in demand for costly treatments such as GLP-1 medications, as well as increased service use across both low- and high-risk populations, contributing to rising claims and pressure on margins.

2. Policy and Structural Challenges Impacting Public Plans: Public health plans are facing intensified financial and regulatory headwinds. Medicare Advantage plans are contending with lower star ratings, increased provider reimbursement demands, and revisions to CMS’s risk-adjustment methodology that could reduce payments. At the same time, Medicaid programs are managing the fallout from pandemic-era enrollment rollbacks, resulting in a higher concentration of costly enrollees, while also bracing for the added strain of anticipated funding cuts and new work requirements.

3. Outlook Remains Uncertain Despite Potential Improvements: While there is cautious optimism that some financial and operational improvements may emerge by 2026, structural challenges in the health insurance industry are expected to persist. Ongoing issues like adverse selection in ACA markets, rising medical costs, and pressure on risk adjustment mechanisms suggest that insurers may continue to face a difficult environment well into 2027 and possibly beyond.

Eli Lilly’s obesity pill helped lower weight, blood sugar in key Phase 3 trial

By Elaine Chen – Eli Lilly’s investigational obesity pill helped lower weight and blood sugar in patients with obesity and type 2 diabetes, but it’s not clear if the Phase 3 results will be enough to assuage concerns about the competitiveness of the drug. The medication, called orforglipron, is the most advanced small-molecule GLP-1 in development. Treatment with the drug led to 9.6% weight loss at the highest dose over 72 weeks, compared with 2.5% in the placebo group when analyzing all participants regardless of discontinuations, Lilly said Tuesday. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Improvement in Blood Sugar Control: Patients receiving the highest dose of the treatment showed a 1.7 percentage-point reduction in their A1C levels, which is a common measure of long-term blood sugar control, compared with a 0.5-point reduction in those on placebo. By the end of the trial, 67% of patients in the highest-dose group reached an A1C below 6.5%—the clinical threshold for diagnosing diabetes—while only 15% of patients in the placebo group were able to achieve that level.

2. Side Effects and Adverse Events: Discontinuations due to adverse events were somewhat higher among those taking the treatment, occurring in 6% to 11% of patients, compared with 5% in the placebo group. The most frequently reported side effects were gastrointestinal issues such as nausea, vomiting, and related discomfort. These reactions were in line with what has been observed in other GLP-1 drug studies, highlighting a known class effect.

3. Overall Discontinuation Rates Comparable: Despite the side effects, the overall dropout rates were similar across both groups, with 19% to 22% of patients in the treatment groups discontinuing compared with 20% in the placebo group. This is notable because, in obesity-related clinical trials, placebo groups often show a higher discontinuation rate due to dissatisfaction with minimal weight loss. In this trial, however, the balance between treatment and placebo discontinuations suggests that the tolerability and expectations may have been somewhat consistent across groups.

Courts press pause on key elements of Trump administration's ACA rule

By Paige Minemyer – A federal judge has blocked multiple provisions of the Trump administration's Affordable Care Act (ACA) overhaul from taking effect Monday as scheduled. The plaintiffs, including multiple large cities like Baltimore and Columbus, Ohio, as well as organizations like the Main Street Alliance, sued in an attempt to block the regulations in early July, arguing they could lead 1.8 million or more people to lose coverage and drive up premiums and out-of-pocket costs. The lawsuit challenges the rule as a violation of the Administrative Procedure Act. Read Full Article...

HVBA Article Summary

1. Court enjoins several rule provisions: Judge Brendan Hurson granted an injunction barring multiple elements of the finalized ACA rule from taking effect until the case is heard. The blocked provisions include a $5 premium penalty on auto-enrollments and a policy that would disqualify individuals from advanced subsidies if they didn't file income taxes or reconcile their tax credits in prior years. The ruling also pauses new calculations around plan tiers and requirements for pre-enrollment eligibility checks for special enrollment periods.

2. Plaintiffs argued the rule would harm coverage and costs: The plaintiffs — which include large cities such as Baltimore and Columbus and groups like the Main Street Alliance — sued in July saying the rule could cause as many as 1.8 million people to lose coverage and raise premiums and out-of-pocket costs. They challenged the rule under the Administrative Procedure Act. The judge found they presented enough evidence to suggest they would likely prevail on seven of the rule's provisions.

3. Some changes were left intact and the injunction's scope is broad: The court did not block all parts of the CMS rule; for example, a shortened open enrollment period on the exchanges was not enjoined. Hurson explained that limiting the injunction only to the plaintiff cities and organizations would be impractical because of the complicated interplay between the ACA and numerous market actors. Plaintiffs celebrated the decision and said they would continue legal efforts to protect access to affordable coverage.

92% of SMBs say policymakers aren’t doing enough on health benefits

By Allison Bell – Owners of small and mid-sized businesses wish policymakers would take more notice of their health benefits problems. About 92% of the owners who participated in a recent online survey agreed with the statement that "government leaders aren't doing enough" to address their health benefits problems. Even more, 93%, agreed that policymakers should come up with a new way for them to offer health benefits. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Widespread concern among SMB owners about policymaker attention: About 92% of surveyed small- and mid-sized business owners said government leaders aren't doing enough to address their health benefits problems, and 93% said policymakers should devise a new way for them to offer health benefits. The sample included about 500 owners of businesses with 500 or fewer employees and the survey was conducted in July. The survey results were summarized by eHealth, the web broker that sponsored the survey.

2. Interest in cash-for-coverage approaches despite limited familiarity: eHealth found that only 46% of employers surveyed were familiar with individual coverage HRAs (ICHRAs), yet 75% said they would like a way to provide defined monetary contributions that workers could use to buy their own coverage. eHealth promotes using ICHRAs and qualified small employer HRAs as vehicles for "cash-for-coverage" plans. By contrast, a separate poll of large employers by the Business Group on Health found only 3% were strongly considering replacing traditional benefits with cash-for-coverage plans.

3. Sustainability worries could reduce employer-offered coverage: Only 12% of business owners offering group health benefits said they were confident they would still be able to do so three years from now, highlighting concerns about affordability. The article notes small employers have been shifting toward self-insured plans in response to rising costs in the fully insured small-group market. It warns that if offering even self-insured plans becomes unaffordable, fewer small employers may offer any group coverage, which could spur greater policymaker attention.

How benefit managers can navigate open enrollment amid OBBBA

By Lee Hafner – President Trump's One Big Beautiful Bill Act has set a variety of changes in motion for employee benefits. Understanding their impact on both businesses and employees will be a crucial part of short- and long-term decision making for leaders. Here are some of the main ways OBBBA's tax cuts and spending reform will affect healthcare, retirement, education and more, and what benefit leaders should prioritize as open enrollment approaches. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Healthcare Funding Cuts May Increase Employer-Sponsored Plan Demand: The One Big Beautiful Bill Act (OBBBA) introduces significant cuts to public healthcare programs — $500 billion from Medicare and nearly $1 trillion from Medicaid — starting in 2026. These reductions are expected to leave around 12 million people uninsured. As a result, employers may face greater pressure to fill coverage gaps through private insurance plans, potentially leading to increased costs and greater responsibility for providing healthcare benefits.

2. Permanent Telehealth Coverage Boosts Access to Care: OBBBA makes permanent the safe harbor allowing high-deductible health plans (HDHPs) to cover telehealth services before deductibles are met. This technical but impactful change enables employers to offer more accessible remote care options, especially benefiting employees with high medical costs or limited access to in-person providers.

3. Shift Toward Value-Based, Preventative Primary Care: Policy changes under OBBBA are accelerating a transition in both private and public healthcare toward preventive and outcome-focused primary care. With new tools and payment models now available, employers have a greater opportunity to improve health outcomes while managing long-term costs by expanding direct primary care and telehealth options for their employees.

Wegovy Approved for MASH With Fibrosis, No Cirrhosis

By Marilynn Larkin – On Friday, the FDA granted accelerated approval to Novo Nordisk’s Wegovy for the treatment of metabolic-associated steatohepatitis (MASH) in adults with moderate-to-advanced fibrosis but without cirrhosis. The once-weekly 2.4 mg semaglutide subcutaneous injection is given in conjunction with a reduced calorie diet and increased physical activity. Read Full Article...

HVBA Article Summary

1. Wegovy Shows Promise in Treating MASH: In the phase-3 ESSENCE trial, Wegovy significantly outperformed placebo in achieving key outcomes for patients with MASH (Metabolic dysfunction-associated steatohepatitis). Specifically, 63% of Wegovy-treated participants experienced resolution of steatohepatitis without worsening liver fibrosis, and 37% showed improvement in liver fibrosis without worsening steatohepatitis by week 72. A third of participants met both criteria, indicating the drug's potential dual benefit.

2. Trial Details Support Clinical Relevance: The trial included 800 adults, most with advanced liver fibrosis (Stage II or III) and other metabolic conditions such as type 2 diabetes. Participants received either Wegovy or placebo alongside lifestyle interventions. The findings — published in a peer-reviewed journal — suggest that Wegovy could be a meaningful treatment option for a high-risk patient population already using medications for glucose, lipid, and weight management.

3. Future Developments and Regulatory Progress: Wegovy is already approved for weight loss and cardiovascular risk reduction in specific populations. Novo Nordisk has filed for additional regulatory approvals in the EU and Japan, and is developing oral formulations of semaglutide, though production limitations may delay launches. The second part of the ESSENCE trial, aiming to evaluate long-term liver-related outcomes, is expected to conclude in 2029.