GOP prepares vote on competing bill addressing ACA subsidy expiration

By Elizabeth Casolo – While Senate Democrats have been gearing up to vote on their ACA enhanced subsidy extension proposal on Dec. 11, Republicans are readying their own bill. “The way the program is structured, the money goes straight to the insurance companies,” Senate Majority Leader John Thune said Dec. 9 of the Democrat-led bill. Read Full Article...

HVBA Article Summary

1. Healthcare Reform Focused on Direct Benefit to Patients: Republican leaders, including Senator Thune and President Trump, emphasize the need for healthcare reforms that prioritize delivering financial benefits directly to patients rather than insurance companies. This approach includes promoting individual control through tools like Health Savings Accounts (HSAs), aiming to empower consumers and reduce perceived inefficiencies in current systems.

2. Republican-Backed Legislation Proposes Structural Changes: A new bill sponsored by Senators Mike Crapo and Bill Cassidy introduces a series of structural reforms to the current healthcare framework. Key provisions include the introduction of HSAs for exchange plan holders, funding for cost-sharing reduction payments, and expanded access to catastrophic coverage. The bill also seeks to limit the use of Medicaid funds and reduce coverage for gender-transition procedures, reflecting broader GOP healthcare priorities.

3. Criticism of ACA and Democratic Inaction on Reform: In response to a recent U.S. Government Accountability Office report citing fraud risks within the Affordable Care Act (ACA), Republican lawmakers renewed their push for substantial reform. Senator Thune criticized Democrats for their unwillingness to engage in changes to the ACA and expressed urgency for action, setting up a pivotal vote to determine the future direction of federal healthcare policy.

CMS' Change Healthcare hack relief funds overpaid most hospitals, missed hundreds of others

By Dave Muoio - Medicare payments fronted by the federal government to providers affected by 2024’s sweeping Change Healthcare cyberattack outage were too large for the majority of recipient hospitals and didn’t reach hundreds of hospitals that experienced substantial revenue disruptions, according to a University of Minnesota analysis. Read Full Article…

HVBA Article Summary

1. Relief Missed by Financially Vulnerable Hospitals: At least 312 hospitals that experienced greater-than-median revenue disruptions during the Change Healthcare cyberattack did not receive any funds from the $3.3 billion CHOPD program. These hospitals disproportionately included rural and critical access hospitals—facilities more likely to be financially strained and dependent on Medicare reimbursements—highlighting gaps in the program's outreach and accessibility.

2. Payment Misalignment with Actual Losses: Among the 476 hospitals that received CHOPD relief (out of 8,538 total providers), about one-third received over $1 million more than their Medicare revenue losses during the disruption window. Conversely, another third of recipient hospitals were underpaid relative to their Medicare losses, in some cases by millions of dollars, pointing to inconsistencies in how relief amounts aligned with actual need.

3. Design Flaws and Improvement Opportunities: CHOPD offered providers up to 30 days of Medicare reimbursement, totaling $3.3 billion, with $2.2 billion going to hospitals. However, payments were recouped within 90 days and made without interest or targeting of high-need recipients, unlike COVID-19 relief efforts. Researchers suggest CMS could reduce overpayments—estimated at a median of $314,302—by lowering the flat payment formula and adding "outlier payments" for severely affected hospitals. They also emphasize the importance of stronger provider outreach in future opt-in programs.

Major public health PBM regulation bill reintroduced

By Allison Bell – The Republican and Democratic leaders of the Senate Finance Committee have teamed up to bring back a major pharmacy benefit manager regulation bill. Sen. Mike Crapo, R-Idaho, the committee chairman, and Sen. Ron Wyden, D-Ore., the highest-ranking Democrat on the committee, joined to introduce the "PBM Price Transparency and Accountability Act" bill. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Bipartisan PBM Reform Bill Gains Momentum with 19 Cosponsors: A newly reintroduced bill aimed at reforming Pharmacy Benefit Managers (PBMs) for public health plans has garnered strong bipartisan support, with 9 Democratic and 10 Republican cosponsors. The legislation proposes detailed reporting requirements for PBMs working with Medicare Part D, mandates that PBMs serving Medicaid pass payments directly to pharmacies, and requires public health plans to allow patients to use any pharmacy that accepts standard contract terms. Importantly, the bill does not address employer-sponsored health plans or their PBMs.

2. Possible Expansion to Employer Plans and Other Health Legislation: While the current bill excludes employer-sponsored plan PBMs, its reappearance suggests lawmakers may push for a broader package. In 2022, a similar PBM reform bill—covering both public and employer plans—was included in a 1,547-page government funding resolution but was later removed. That version would have required PBMs for large fully insured or self-insured employer health plans to pass 100% of prescription drug rebates and discounts to the plan sponsor, and to follow detailed reporting rules.

3. Legislative Setbacks Give Way to Renewed ACA and Health Benefit Talks: Previous PBM reform efforts were removed from final legislation despite strong bipartisan backing, but recent developments point to renewed opportunities. Sen. Bill Cassidy (R-La.), chair of the Senate HELP Committee, voiced optimism on Dec. 3 about advancing ACA-related legislation, including an extension of current ACA subsidies that are set to expire Dec. 31. At that hearing, industry stakeholders advocated for including association health plans and health reimbursement arrangements as part of any upcoming health reform package.

DC Plan Loan Usage Correlates With Health Care Spending, per EBRI

By Emily Boyle - Participants who took loans from their 401(k) plans in 2021 and 2022 may have used them to finance heightened health care expenditures, according to an issue brief from the Employee Benefits Research Institute, released December 4. Among those participants with a new 401(k) plan loan, health care was the most likely of 12 spending categories to have increased, as 51% of households with a participant who took a loan increased their health care spending by at least 10% in the year during which they took the loan. In households that did not take a new loan, health spending was likely to have increased for almost half (47.8%) of respondents. Read Full Article…

HVBA Article Summary

1. Retirement Plan Loans Are Driven by Immediate Financial Stressors, Especially Health Care: A key reason participants take 401(k) loans is to address short-term liquidity needs, often due to unexpected health care expenses. Among financially stressed households with participants aged 50 or older, 58.7% experienced increased health care spending, compared to just 47.5% of similar households that didn’t take loans. Common spending areas that increased by at least 5 percentage points in the year a loan was taken included unspecified cash spending (22.8%), housing (21%), and health care (19.7%).

2. Health Care Costs Are Delaying or Disrupting Retirement Plans for Many Americans: According to a 2025 survey by the Nationwide Retirement Institute, 55% of U.S. adults worry that health care costs will delay or prevent retirement, while 51% say medical expenses have significantly reduced their ability to save. Additionally, 41% of insured individuals skipped medical appointments due to cost, 31% couldn’t afford an unexpected $500 medical bill, and 66% were unable to estimate their lifetime medical costs—highlighting widespread uncertainty and vulnerability.

3. Loan Likelihood Not Tied to Income, But to Credit Card Use and Financial Behavior: The EBRI study found that 9% to 10% of participants across all income levels took a 401(k) loan, suggesting income alone isn’t the main factor. Instead, higher credit card utilization was more strongly associated with loan activity and lower retirement contributions. For example, participants in their 50s with high credit card usage contributed an average of 5.6%, compared to 7.6% among their peers with lower utilization—leading to lower account balances and heightened long-term financial risk.

Trump's idea for health accounts has been tried. Millions of patients have ended up in debt

By Noam N. Levey, KFF Health News - Sarah Monroe once had a relatively comfortable middle-class life. She and her family lived in a neatly landscaped neighborhood near Cleveland. They had a six-figure income and health insurance. Then, four years ago, when Monroe was pregnant with twin girls, something started to feel off. Read Full Article…

HVBA Article Summary

1. High-Deductible Health Plans Often Lead to Significant Financial Strain: While intended to reduce costs and empower patients, high-deductible health plans have left many insured individuals—like Monroe—struggling with medical debt. Despite having insurance and a health savings account, Monroe faced over $13,000 in debt due to uncovered medical expenses, a situation common among the estimated 100 million Americans with healthcare debt.

2. The Intended Consumer Empowerment Has Not Materialized as Expected: Policymakers and proponents of high-deductible plans argue they encourage patients to shop around for lower-cost care. However, this is often unrealistic for people with emergencies or complex conditions. Research shows only a small fraction of healthcare spending is for services that can practically be comparison-shopped.

3. Policy Debate Continues as Costs and Consequences Mount: Republicans, including Donald Trump and GOP lawmakers, continue to support models that combine high-deductible plans with healthcare savings accounts, promoting them as a patient-empowering option. However, critics and experts argue these plans can exacerbate health risks and financial instability for people with serious conditions, prompting calls for alternative approaches to healthcare reform.

Sustainable strategies for avoiding the GLP-1 cliff

By Dr. Tim Church – Employers are facing one of the fastest-rising costs in healthcare today: GLP-1 medications prescribed now account for 17% of U.S. employer pharmacy claims, in large part due to the increased demand for weight-loss medications. Beyond cost, there are additional GLP-1 challenges that employers are experiencing, including growing demand, emerging indications and adherence issues. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. GLP-1 Discontinuation Undermines Long-Term Outcomes Without Sustained Support: Originally developed for type 2 diabetes, GLP-1 medications are now used to treat obesity and related conditions. However, nearly 30% of users stop taking them within six months, often due to side effects, cost, or lack of ongoing care. These medications require behavior-change support and individualized guidance to drive lasting improvements in health, beyond initial weight loss.

2. Employers Face Risks Without Integrated, Durable Obesity Care Strategies: The "GLP-1 cliff" refers to the sharp drop in outcomes when medication support ends abruptly. Employers are cautioned not to rely solely on access or participation metrics. Instead, successful programs integrate with existing care benefits, adapt to diverse employee needs, and include mechanisms to support maintenance post-medication. Without this, employers may see increased claims, disengagement, and wasted investment.

3. Vendor Selection Should Prioritize Measurable, Sustainable Results Over Hype: Despite pressure to offer GLP-1 coverage—especially with 44% of employees willing to switch jobs for access—only 28% of larger employers do. Employers should vet vendors using criteria such as long-term outcome tracking, transition planning after treatment ends, system integration, and financial risk-sharing. Programs focused only on sign-ups or siloed delivery may fail to deliver real, lasting value.

Employees can subscribe to dental care benefits

By Tyler Burnett – Eight years ago, I walked into a dentist's office with a toothache and walked out with a treatment plan for eight cavities, a huge bill, and weeks of pain. After getting second and third opinions, I learned I needed just one filling, not eight. That experience taught me what many Americans already know: traditional health care doesn't work for people facing sky-high living costs and unpredictable coverage. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Traditional Dental Benefits Are Declining Amid Workforce Shifts: Dental care, once a staple of American employee benefits, is increasingly being reduced or eliminated due to rising health care premiums and a shifting workforce. With the growth of gig workers, freelancers, and part-time employees, only 25% of gig workers have dental insurance, compared to 66% of full-time employees. This change has created significant gaps in access, leaving millions to navigate a costly and fragmented dental care system without sufficient support.

2. Preventive Dental Care Remains Out of Reach for Many Americans: Despite 75% of Americans planning to visit the dentist annually, only 35% actually do—a reflection of systemic challenges like high deductibles, surprise billing, long wait times, and limited provider networks. As dental care is often seen as non-essential, many workers delay treatment until it becomes an emergency, leading to ER visits that cost thousands of dollars and reduce workplace productivity. These issues are especially severe in high-cost cities like New York and San Francisco, where housing expenses make routine care unaffordable for many.

3. Subscription-Based Dental Models Are Gaining Ground as Practical Alternatives: As employer-sponsored benefits shrink, subscription and membership-based dental care models are growing in popularity. These approaches eliminate traditional insurance barriers, offering predictable, transparent pricing and encouraging more frequent preventive care. For example, Wally Health’s 25,000 members average three to four cleanings per year, compared to the national average of one. These models align provider incentives with patient health outcomes and provide an appealing, low-overhead solution for HR professionals looking to support a diverse workforce without ballooning benefit costs.