Report: Health insurance costs take a bigger bite from small firm employees’ paychecks

By Erik Gunn - For employees of small businesses, health benefits cost more and cover less than they do for employees of large companies, according to a new report released Tuesday. Read Full Article… 

HVBA Article Summary

1. Rising Costs and Challenges for Small Businesses: Employees of small firms, such as those in Wisconsin, face significantly higher health insurance premiums and deductibles compared to their counterparts in large firms. On average, Wisconsin small business employees pay over $1,300 more annually for premiums and nearly $1,400 more in deductibles, reflecting a national trend driven by the limited bargaining power and higher administrative costs faced by small businesses.

2. Adaptive Strategies to Manage Health Coverage: Small businesses like Wonderstate Coffee are adopting innovative approaches to manage escalating health insurance costs. Wonderstate transitioned to a level-funded plan to stabilize expenses, paying a fixed monthly amount to cover healthcare costs, supplemented by catastrophic coverage. Such strategies are increasingly common, with 40% of small-firm employees nationwide covered by self-funded or level-funded plans, which, however, lack some ACA protections.

3. Policy Recommendations to Support Small Firms and Employees: The Commonwealth Fund report outlines several policy options to alleviate the financial strain on small businesses and their employees. Recommendations include enhancing and making permanent subsidies for low-income individuals purchasing insurance through Healthcare.gov, expanding Medicaid or creating federal fallback plans, and informing eligible workers about Medicaid. These measures aim to make healthcare more accessible and affordable for small-firm employees and stabilize the market.

5 principles for optimizing GLP-1s

By Dr. Lisa Shah - Over 40% of people in the U.S. are living with obesity and over 11% have Type 2 Diabetes. Metabolic disease is a public health crisis that is driving unsustainable health care spending. Diabetes care alone now exceeds $410 billion annually, with much of that burden shouldered by employers, who cover direct costs like medication and treatment, and individuals who face expensive co-pays and rising health insurance premiums. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Understanding Individual Responses to GLP-1s: The effectiveness of GLP-1 medications varies widely among individuals, with users falling into categories such as super responders, general responders, or non-responders. Regular check-ins and personalized monitoring are critical to determine the drug’s ongoing impact and avoid wasteful spending.

2. Personalization and Sustained Metabolic Health: While GLP-1s can effectively initiate weight loss, their long-term success depends on integrating lifestyle changes tailored to each individual’s metabolic profile. Employers should invest in tools and algorithms that provide insights into metabolism, enabling customized nutrition and activity plans to sustain benefits.

3. Strategic Use and Exit Plans for GLP-1s: GLP-1s are not designed for lifetime use, necessitating clear off-ramp strategies. Employers must monitor treatment efficacy, adjust usage as needed, and develop precise interventions to support weight maintenance after GLP-1s, ensuring cost-effective and sustainable health outcomes.

Drowning with a life-preserver: What it means to be functionally uninsured in America

By Stephanie Koch - When people pay for insurance — whether it's on a home, automobile or something as precious as their own health — they rightfully expect a certain amount of help in the event of an emergency. A new car to replace a vehicle totaled in a crash. A new roof to repair the damage from a surprise windstorm. Or financial relief to help cover the cost of a serious medical diagnosis.  Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Growing Crisis of the Functionally Uninsured: Many Americans, despite having health insurance, are finding themselves unable to afford necessary care due to high deductibles, premiums, and out-of-pocket costs. This creates a significant financial strain, forcing difficult choices like skipping essential care or cutting household expenses, which impacts both physical and financial well-being.

2. Innovative Employer Solutions for Affordable Healthcare: Employers like Hendry Marine are turning to alternative health plan models, such as self-funded plans with reference-based pricing, to manage rising healthcare costs. These approaches not only lower expenses but also enable companies to reinvest savings into preventive care initiatives, such as on-site clinics, improving accessibility for employees.

3. The Path Forward: Addressing Healthcare Inefficiencies: To combat the dual crises of medical debt and insufficient access to care, employers must address the inefficiencies within traditional insurance models. By prioritizing transparency, preventive care, and affordability, businesses can contribute to a healthier workforce while reducing the financial burden on families and ensuring long-term sustainability.

Democrats propose deal to GOP extending Affordable Care Act subsidies by a year

By Dan Diamond and Rachel Roubein - Congressional Democrats have privately proposed a deal to Republicans that would extend expiring Affordable Care Act subsidies by one year, with lawmakers worried by new estimates that 2.2 million people will otherwise lose health coverage, according to five people who spoke on the condition of anonymity to discuss the proposal. Read Full Article…

HVBA Article Summary

1. Key Negotiations on Health-Care Policies: Lawmakers are working on year-end spending legislation, with Democrats and Republicans debating critical health-care proposals. Among the priorities are an extension of ACA subsidies, more funding for community health centers, reforms targeting pharmacy benefit managers (PBMs), and expansions of telehealth coverage under Medicare. Democrats aim to secure a one-year extension of ACA subsidies to maintain insurance affordability for millions, while Republicans weigh concerns about federal spending and tax credits.

2. Impact of Expiring ACA Subsidies: Projections from the Congressional Budget Office (CBO) and other organizations highlight the significant consequences of allowing ACA subsidies to lapse. Without action, millions of Americans could lose health coverage, with estimates predicting a rise in the uninsured rate by up to 3.8 million annually starting in 2026. Democrats propose funding the subsidy extension through budget sequestration, while Republicans critique the initiative as a costly federal program that aids individuals not traditionally needing assistance.

3. Democratic Proposals to Broaden Health-Care Coverage: In addition to addressing ACA subsidies, Democrats propose tackling rising medication costs by reforming PBM practices, extending Medicare telehealth provisions, and improving access to mental health care. These measures aim to strengthen health-care access for vulnerable populations, with bipartisan support growing for certain reforms like reducing PBM-driven drug costs. However, GOP leaders remain skeptical, leaving the future of these initiatives uncertain amidst tense negotiations.

US Supreme Court will not hear drug industry challenge to Arkansas contract pharmacy law

By Brendan Pierson - The U.S. Supreme Court on Monday declined to hear an appeal by the nation's leading drug industry group challenging an Arkansas law requiring pharmaceutical companies to offer discounts on drugs dispensed by third-party pharmacies that contract with hospitals and clinics serving low-income populations. Read Full Article…

HVBA Article Summary

1. Legal Challenge and Industry Opposition: PhRMA and individual drugmakers have filed multiple lawsuits challenging state laws, like Arkansas's, that protect hospitals' ability to use contract pharmacies under the federal 340B discount program. They argue that these state laws conflict with federal statutes and that the contract pharmacy system is susceptible to misuse, leading to duplicate discounts and reduced transparency.

2. Court Rulings and State Actions: Both a district court and the 8th U.S. Circuit Court of Appeals upheld Arkansas's law, asserting that while the federal 340B program mandates discounted drug sales, it does not specify the delivery mechanism, leaving room for state regulation. Other states, including Maryland, West Virginia, and Mississippi, have enacted similar laws to safeguard contract pharmacies' role in the program.

3. Implications for Drug Access and Policy Reform: Arkansas Attorney General Tim Griffin praised the court decision as a victory for equitable drug access in rural areas, highlighting a perceived gap in federal law that state legislation aims to address. Meanwhile, PhRMA continues to advocate for federal intervention to reform the 340B program, citing concerns about its administration and potential abuse.

Federal court blocks ACA coverage for Dreamers

By Tara Suter - A federal court in North Dakota has blocked Affordable Care Act (ACA) coverage for immigrants that came into the U.S. illegally as children, also known as “Dreamers.” Read Full Article…

HVBA Article Summary

1. Stay and Injunction Granted: U.S. District Judge Daniel M. Traynor issued a stay and preliminary injunction in favor of Kansas and 18 other states, preventing the Biden administration from enforcing its final rule that allows DACA recipients access to the ACA marketplace. The court ruling challenges the administration's authority to redefine "lawfully present" for health care eligibility.

2. DACA Recipients' Coverage History: The Biden administration's final rule, announced in May, aimed to expand ACA coverage options for DACA recipients, addressing previous CMS rules that excluded them from coverage by categorizing them as not "lawfully present." Judge Traynor's ruling asserts that CMS exceeded its authority by altering the definition of lawful status without congressional approval.

3. Legal and Political Reactions: Kansas Attorney General Kris Kobach hailed the ruling as a victory for the rule of law, arguing that the Biden administration's actions violated congressional intent and existing laws. Meanwhile, a CMS spokesperson stated the agency is reviewing the decision but refrained from commenting on ongoing litigation.

States should regulate single-state self-insured health plans, not ERISA, say lawmakers

By Allison Bell - Members of state legislatures are looking for a way to regulate self-funded employer plans. The National Council of Insurance Legislators held a general session on the impact of the Employee Retirement Income Security Act of 1974 on state health insurance regulation last month in San Antonio, during NCOIL's annual meeting. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. The Growing Conflict Between ERISA Preemption and State Health Policy Reforms: While ERISA was initially designed to prevent pension fraud and establish federal standards, its broad preemption of state laws has increasingly clashed with state efforts to regulate healthcare, especially as smaller employers use self-funded plans with stop-loss insurance. This tension is prompting state legislators to call for reforms that would grant them greater control over healthcare regulations affecting self-insured plans.

2. Supreme Court Decisions and ERISA’s Evolving Landscape: The U.S. Supreme Court has historically upheld ERISA preemption, limiting states’ ability to regulate self-funded plans. However, the 2020 Rutledge v. Pharmaceutical Care Management ruling opened the door for states to regulate pharmacy benefit managers, suggesting a potential pathway for further exceptions to ERISA’s preemption. Advocates argue that such exceptions are necessary to empower states to address healthcare cost and access issues effectively.

3. Divergent Perspectives: State Legislators vs. Employer Benefits Groups: Efforts to narrow ERISA preemption are creating a divide between state policymakers and groups representing self-insured employers. While state representatives seek more authority to enact healthcare reforms, organizations like the ERISA Industry Committee caution against weakening national uniformity, warning it could lead to increased administrative burdens and higher costs for employers and employees alike.