House passes health benefits package with a 216 to 211 vote

By Allison Bell – Members of the U.S. House voted 216 to 211 Wednesday to pass the Lower Health Care Premiums for All Americans Act bill — a package that includes proposals that have been on some employers' and benefits advisors' wish lists for years. The package would address the Affordable Care Act "premium subsidy cliff" by providing funding for the ACA cost-sharing reduction subsidy, rather than trying to keep ACA premium subsidies for individual and family health coverage purchased from HealthCare.gov or another ACA public exchange at a high level. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. House Republicans Passed a Health Benefits Package with Key Changes, but Senate Passage Is Unlikely: The package includes provisions to loosen regulations around stop-loss insurance, expand association health plans (AHPs), and establish a new framework for individual coverage HRAs (rebranded as CHOICE arrangements). Despite nearly unanimous Republican support, the bill lacks Democratic backing and faces strong opposition in the Senate, making its enactment uncertain.

2. Supporters Argue the Provisions Offer Cost Savings and Flexibility for Employers and Workers: Republicans emphasized that the bill could reduce employer health coverage costs and give employees more control over healthcare spending. Cited benefits include potential cost reductions from stop-loss coverage and broader access to AHPs for small businesses. Proponents say CHOICE arrangements allow workers to select more suitable, cost-effective plans.

3. Critics Warn of Coverage Gaps, Market Destabilization, and Rising Costs for Vulnerable Groups: Democrats expressed concern that the changes could lead to coverage denial for people with preexisting conditions and weaken traditional insurance markets by segmenting healthier groups. They also criticized the omission of an ACA premium subsidy extension, which could significantly raise healthcare costs for moderate- and higher-income users when it expires at year’s end.

CMS unveils LEAD, its new 10-year accountable care model

By Paige Minemyer - The Trump administration has revealed what comes next when the ACO REACH model concludes at the end of 2026. The Center for Medicare and Medicaid Innovation unveiled the Long-Term Enhanced ACO Design, or LEAD, model Thursday as its newest accountable care program. LEAD will be a decade-long voluntary program that begins Jan. 1, 2027 and concludes Dec. 31, 2036. Read Full Article…

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1. Expanded Access and Support for Providers: The CMS LEAD model is designed to lower entry barriers and reduce attrition among healthcare providers in Accountable Care Organizations (ACOs), with a focus on including previously underserved groups such as rural physicians and community health centers. By offering enhanced and flexible cash flow payments, LEAD allows providers to spend more time with patients and encourages proactive engagement between visits. The model aims to strengthen long-term relationships between patients and providers and promote a more connected and needs-based approach to care for Medicare beneficiaries.

2. Flexible Risk-Sharing Options and Medicaid Integration Plans: To accommodate varying levels of provider readiness and risk tolerance, LEAD offers two risk-sharing arrangements: a global option with 100% upside and downside risk, and a professional option with 50% shared savings and losses. Additionally, CMS plans to pilot Medicaid integration in two states during an initial planning phase from 2026 to 2027. This phase will focus on building a collaborative framework that enables ACOs and Medicaid organizations to coordinate care more effectively, improve data sharing, and reduce preventable hospitalizations, particularly for high-needs populations.

3. Long-Term Innovation Goals with Transition Challenges: The model’s 10-year demonstration period is intended to give ACOs the stability to make long-term investments and implement innovative care strategies. Advocacy groups such as Accountable for Health and the National Association of ACOs (NAACOS) have expressed strong support for the model’s emphasis on primary care, equity, and high-needs patients. However, concerns have been raised about the tight timeline for transitioning from the existing ACO REACH model to LEAD. Stakeholders are urging CMS to extend the REACH program through 2027 to provide ACOs with adequate time to plan and adapt to the new framework.

Exclusive research: Benefit leaders face a pharmacy cost crisis in 2026

By Alyssa Place – As employers head into 2026, managing pharmaceutical costs is becoming increasingly complex, driven by a convergence of rising drug prices, increased utilization of specialty medications, and continued friction within the pharmacy supply chain. Benefit managers are under pressure to balance cost containment with employee access and affordability, particularly as high-cost specialty medications account for a growing share of total pharmacy spend. Read Full Article... ^{_{(Subscription required)}}

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1. Limited Transparency and Resources Hinder Strategic Shifts: Employers face challenges in managing pharmacy costs due to opaque pricing, complex rebate structures, and restrictive contracts with pharmacy benefits managers (PBMs). These issues, combined with evolving employee expectations and regulatory uncertainty, make it difficult for organizations to adopt more innovative or cost-effective pharmacy benefit models, despite growing interest.

2. Traditional Pharmacy Management Models Still Prevail: A majority of employers (69%) include pharmacy coverage within their major medical plans, and 50% continue to partner with traditional PBMs. While awareness of alternative cost-containment approaches is increasing, actual adoption remains low: only 16% of employers use transparent or pass-through PBMs, and just 13% engage in coalition purchasing or group captives. Direct contracting with independent or international pharmacies sees even lower adoption rates, with many employers either only aware of these models or unfamiliar with them entirely.

3. Employers Favor Low-Friction Strategies Like Generics and Prevention: Instead of overhauling benefit structures, most employers—especially mid-sized ones—prioritize promoting generic drug use, with 66–75% reporting this approach. Preventive care and integrated well-being programs are also common tactics to reduce long-term medication costs. Larger organizations (2,000+ employees) are significantly more likely to renegotiate terms with PBMs or brokers, adopt transparent PBMs, or develop separate pharmacy plans—demonstrating how scale and resources enable more advanced strategies.

Why health insurance is getting more expensive

By Caitlin Owens - There's a good chance your health insurance premiums are going up next year, regardless of where you get coverage. Why it matters: The spike in what millions of Affordable Care Act plan enrollees pay will be acute, but workplace insurance is getting more expensive, too — and all at a time when affordability is prominently on Americans' minds. Read Full Article…

HVBA Article Summary

1. Steep Increases in Health Insurance Premiums Across the Board: Health insurance premiums are projected to rise sharply in 2026. ACA marketplace insurers are increasing premiums by an estimated 26%, driven by higher hospital costs, increased use of expensive GLP-1 drugs like Ozempic, and other factors. When accounting for the potential expiration of federal subsidies, the effective increase could be as high as 114%, according to KFF. Similarly, small group employer plans are expected to see a median increase of 11%, while large employer-sponsored plans may rise 6.5% per employee, per Mercer. These increases reflect both higher medical costs and increased healthcare utilization post-pandemic.

2. Political Stalemate Threatens Relief as Costs Become a Campaign Issue: Despite weeks of debate in Congress, there is no legislative momentum to address rising premiums. While extending enhanced ACA subsidies from the Biden era remains a Democratic priority, most Republicans oppose it, and even such an extension wouldn't tackle the broader cost drivers. With the 2026 midterms approaching, Democrats are expected to spotlight Republican inaction on health costs across all insurance types, further politicizing the issue without offering immediate solutions.

3. Affordability Crisis Deepens Amid Shifting Public Sentiment and Behavior: Rising premiums and out-of-pocket expenses are forcing difficult decisions on families, workers, and employers, with some potentially going uninsured due to cost. Advances in expensive treatments (e.g., cancer therapies) and increased demand for care — boosted in part by AI-driven efficiency in doctors' offices — are fueling higher usage. Public concern is also mounting: a recent Gallup poll found 29% of Americans now see cost as the country’s most urgent health issue, up from 23% last year. Meanwhile, ACA approval hit a record 57%, with over 60% of independents supportive, but only 15% of Republicans.

Long-term care costs are a major threat to retirement security

By Alan Goforth - Regardless of how well someone has planned for retirement, paying for long-term care can be financially and emotionally overwhelming. Seniors needing long-term care will pay an average of $138,000 each year, according to the U.S. Department of Health and Human Services. Although it may be tempting for healthy people to assume they never will need such care, a 65-year-old has a 7 in 10 likelihood of needing some form of long-term care during their remaining lifetime. Nevertheless, only 3% of Americans own any type of long-term care insurance, according to LIMRA estimates. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Workplace Long-Term Care Benefits Are Valued but Underutilized: Although standalone and hybrid retail long-term care (LTC) insurance products exist, the workplace presents a valuable, yet underused, channel for helping employees begin LTC planning. According to LIMRA, 2 in 5 employees (40%) consider long-term care insurance a very important benefit, yet only 1 in 5 (20%) say it is actually offered by their employer. Moreover, over half of employees are unsure whether such a benefit is even available to them, highlighting both a communication and access gap in the workplace.

2. Employer Awareness and Offerings Are Growing: Employers are increasingly aware of the growing demand for LTC benefits. Over half (54%) expect their employees to be very interested in long-term care insurance within the next five years. In response, many employers are expanding their benefits packages to include caregiving support and paid family medical leave, addressing broader aspects of long-term care beyond insurance.

3. Younger Adults Could Gain Long-Term Value Through Workplace Access: Although most LTC insurance marketing targets older adults, workplace solutions can especially benefit younger employees—particularly millennials—by enabling them to lock in lower premiums and access combination life insurance products that include LTC coverage. LIMRA research indicates that more insurance carriers are likely to introduce workplace-based LTC solutions, and supportive regulations like the Washington Cares Act may further improve the market environment. Targeting recent caregivers and small businesses may also help broaden adoption and reach untapped audiences.

Growing GLP‑1 drug costs squeeze Minnesota employers and health plans

By Torey Van Oot - Surging demand for Ozempic and other GLP-1 drugs is adding up for some Minnesota employers. Why it matters: The popular medications are changing lives and health outcomes for the better. But the high price tag is also driving up health care costs for employers and their workers, prompting some workplaces to scale back coverage. Read Full Article…

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1. MAC to End Weight Loss Drug Coverage Over Rising Costs: The Metropolitan Airports Commission (MAC) will discontinue coverage of GLP-1 drugs such as Ozempic for weight loss in 2025, affecting roughly 800 employees. The decision is driven by rapidly increasing demand and the high cost of these medications, which average $6,000 per user annually. Coverage will still be maintained for GLP-1 drugs when prescribed for diabetes.

2. Employer Health Plans Are Under Pressure from Surging GLP-1 Usage: A broader trend shows employer-sponsored health plans facing steep cost increases due to the popularity of GLP-1 medications for weight management. For example, spending by Minnesota's state employee health plan rose from $13 million in 2023 to $45 million in just the first half of 2024. These drugs now account for about 9% of the plan’s total spending, compared to just 1% in 2022.

3. Tighter Coverage Policies Emerge Amid Cost Concerns and Policy Shifts: In response to growing financial strain, many employers and states are implementing stricter eligibility rules for GLP-1 coverage, such as requiring BMI thresholds and participation in weight management programs. While some states have scaled back coverage, advocates argue that long-term health benefits and potential savings justify continued access. At the same time, pharmaceutical companies are under pressure to reduce prices, with new lower-cost options expected soon, including a $350/month version through the TrumpRx website launching next year.

Alcohol Consumption and Breast Cancer Risk

By Mike Bassett – Multiple studies have linked alcohol consumption to an increased risk of breast cancer, and binge drinking may exacerbate that risk. "There's indeed overwhelming evidence that consuming alcohol is associated with an increased risk [of breast cancer]," said Julie Palmer, ScD, MPH, of Boston University, during a session at the recent San Antonio Breast Cancer Symposium (SABCS). "There may be no safe level, but we're not sure." Read Full Article...

HVBA Article Summary

1. Binge Drinking Is Rising Among Women and May Elevate Breast Cancer Risk: Although binge drinking was once far more common among men (81% of episodes two decades ago), recent trends show a sharp rise among women. This increase has occurred alongside a growing incidence of early-onset breast cancer, particularly in women under 40. Public health experts are increasingly concerned that these patterns may be linked and could contribute to higher breast cancer rates in the future.

2. Binge Drinking May Pose Unique Risks Beyond Regular Alcohol Use: Evidence from several large studies shows that binge drinking is associated with a significantly higher risk of breast cancer, separate from total alcohol intake or drinking frequency. For instance, women who binge drank had up to a 76% higher risk, and premenopausal women faced double the risk compared to non-binge drinkers. Even moderate drinkers who engaged in binge drinking were found to have greater risk than low-level drinkers who abstained from binging.

3. Clinical and Public Health Opportunities Are Being Missed: Despite growing data, most individuals who binge drink do not receive counseling from healthcare providers. A CDC survey found only 41.7% of binge drinkers were advised about alcohol harms during checkups, and only 13.7% of women were specifically told to reduce drinking. Experts stress that this lack of clinical guidance represents a critical missed opportunity for prevention and early intervention in cancer risk.