Hawley and Warren Introduce “Break Up Big Medicine Act” to Force Separation of Insurers, PBMs and Providers

By Wendell Potter – [Yesterday], Senate ideological-opposites, Sen. Josh Hawley (R-Mo.) and Sen. Elizabeth Warren (D-Mass.), introduced the Break Up Big Medicine Act, a Glass Steagall Act for health care. From the right, Hawley has built a reputation as a populist critic of corporate exploiters. From the left, Warren has spent years hammering Wall Street and Big Tech for their grip on markets. Together, their new bill aims at the corporate, monopolistic conglomerates that now control much the U.S. health care system — particularly where Big Insurance and its subsidiaries blur the lines between health delivery and Wall Street calculations. Read Full Article...

HVBA Article Summary

1. Bipartisan Effort to Address Health Care Consolidation: Senators Hawley and Warren, despite their differing political backgrounds, have joined forces to introduce legislation targeting the growing consolidation in the health care industry. Their bill seeks to dismantle vertically integrated health conglomerates by requiring companies to separate ownership of insurance, pharmacy benefit management, and provider organizations. This approach is modeled after the Glass-Steagall Act, which historically separated commercial and investment banking to protect consumers.

2. Legislation Targets Self-Dealing and Cost Inflation: The proposed act aims to prevent health care companies from engaging in self-dealing practices that exploit regulatory loopholes, such as the medical loss ratio requirement. By owning multiple entities across the health care supply chain, large corporations can shift funds internally and inflate costs, ultimately increasing profits while reducing incentives to control expenses. The bill would require divestment within one year of enactment, with enforcement by the Federal Trade Commission.

3. Broader Implications for Health Care Affordability: The introduction of this legislation reflects a growing national concern over health care affordability and the influence of large insurance conglomerates. The bill is positioned as a proactive measure to prevent a crisis similar to past financial collapses caused by unchecked industry integration. Its supporters argue that structurally separating these entities could help protect patients, improve price transparency, and address the medical debt crisis affecting many Americans.

Kaiser reaches $30 million settlement with US Labor Dept over mental health care practices

By Sneha S K – The U.S. Department of Labor said on Tuesday it has settled with Kaiser Foundation Health Plan to resolve multiple investigations into the company's practices on mental health and substance use disorder services. The agreement resolves allegations that Kaiser failed to maintain adequate provider networks for mental health and substance use disorder care, and improperly used patient responses to questionnaires to deny care, the Labor Department said in its statement. Read Full Article...

HVBA Article Summary

1. Settlement Details and Financial Penalties: Kaiser Foundation Health Plan agreed to a $30 million settlement with the U.S. Department of Labor, which includes compensating members for out-of-network mental health and substance use disorder services and paying a penalty to the federal government. This settlement addresses costs incurred by members who had to seek care outside of Kaiser’s network. The agreement also includes a $2.8 million penalty, highlighting the seriousness of the alleged violations.

2. Allegations of Inadequate Care and Denial Practices: The investigations found that Kaiser allegedly failed to provide sufficient access to mental health and substance use disorder care by not maintaining adequate provider networks. Additionally, the company was accused of using patient questionnaire responses as a basis to deny necessary care. These practices raised concerns about whether members were able to receive timely and appropriate treatment for their mental health needs.

3. Commitment to Policy Reforms and Future Improvements: As part of the settlement, Kaiser has committed to reforming its policies, including reducing appointment wait times and improving care review processes to ensure members receive medically necessary care. The company stated it has already made enhancements to its mental health care delivery system and acknowledged ongoing efforts to better align services with patient expectations. The settlement does not address current practices, but Kaiser’s public statement indicates a willingness to continue improving patient outcomes.

CMS offers rules to lower healthcare costs

By Madeline Ashley – CMS unveiled a proposed rule Feb. 9 that would reshape the ACA marketplace for plan year 2027, expanding insurer flexibility on plan design, tightening eligibility verification, and re-introducing several program integrity measures that were blocked by a federal court last year. The proposal arrives at a turbulent period for the individual market. Enhanced premium tax credits expired at the end of 2025 after congressional negotiations to extend them collapsed, leading to about 1.5 million fewer plan selections for 2026 so far, according to the latest CMS data. Read Full Article...

HVBA Article Summary

1. Expanded Plan Design Flexibility and State Autonomy: CMS proposes allowing multi-year catastrophic plans up to 10 years and certifying non-network indemnity-style plans for QHP status starting in 2027. Standardized plan requirements would be repealed, and bronze and catastrophic cost-sharing rules revised beginning in 2027. States would gain more control over provider certification and enrollment systems, with reduced ECP thresholds from 35% to 20% and elimination of certain federal network adequacy standards.

2. Tightened Eligibility Requirements and Integrity Oversight: CMS seeks to verify at least 75% of SEP enrollments pre-enrollment, make income documentation mandatory for those under 100% FPL, and permanently remove income attestations when IRS data is unavailable. Starting in 2027, eligibility for premium tax credits would be limited to a narrower group of noncitizens, excluding refugees, asylum recipients, and others. The 150% FPL special enrollment period would expire after 2026, and noncitizens under 100% FPL would lose tax credit access.

3. Increased Accountability, Transparency, and Financial Oversight: The rule expands CMS authority to audit plans annually or as-needed and penalize state-based plans if states don’t enforce rules. Marketing restrictions would target deceptive practices like cash incentives or misleading $0 plans, while brokers must use standardized HHS forms. CMS also proposes banning adult dental as an essential benefit, keeping risk adjustment fees at $0.20 PMPM, and requests input on changing the 80/20 medical loss ratio rule even without state requests.

Cigna Executives See Little ’26 Movement in Enrollment, Cost Ratio

By Geert De Lombaerde – The leaders of Cigna Inc. say price hikes they’ve pushed through in various parts of the company’s insurance operations, which last year pulled in more than $47 billion in revenue, won’t lower the company’s medical care ratio this year. But they are forecasting that the Cigna Healthcare group will grow pre-tax operating profits by at least 8 percent this year. Chairman and CEO David Cordani and his team told analysts and investors Feb. 5 that they aren’t counting on Cigna Healthcare’s member base to grow from the roughly 18.1 million people enrolled at the end of 2025. Inside that group, however, the company expects to add members in its middle, select and international markets while losing some national accounts and again shrinking its individual exchange business. Read Full Article...

HVBA Article Summary

1. Stable Medical Care Ratio Forecast: Cigna Healthcare reported a full-year medical care ratio of 84.4 percent in 2025, which was an increase from 2024 primarily due to higher medical costs in individual and family plans. For 2026, the company forecasts a medical care ratio between 83.7 percent and 84.7 percent, indicating little expected change despite premium increases. This stability suggests that pricing improvements are balanced by member mix factors and the absence of one-time benefits from the previous year.

2. Enrollment Trends and Market Shifts: While Cigna does not expect overall growth in its member base from the 18.1 million enrolled at the end of 2025, it anticipates gains in middle, select, and international markets. Conversely, the company expects losses in national accounts and a continued decline in its individual exchange business, with fewer than 300,000 customers projected on exchanges by the end of 2026. This reflects a strategic shift in focus and market segmentation within Cigna's insurance operations.

3. Economic and Operational Outlook: Cigna executives, including President Brian Evanko and CFO Ann Dennison, report no unusual economic conditions affecting enrollment or cost ratios. They emphasize prudence in their assumptions given the ongoing elevated cost environment and note that macroeconomic factors such as unemployment have not impacted their outlook. The company expects pre-tax adjusted operating income for Cigna Healthcare to grow to at least $4.5 billion in 2026, up from $4.15 billion in 2025.

CMS plans to roll back limits on nonstandard ACA plan options

By Paige Minemyer – The Trump administration is aiming to roll back limits on the plan designs insurers can offer on the Affordable Care Act's (ACA's) exchanges. Under the Biden administration, the Centers for Medicare & Medicaid Services (CMS) implemented regulations that limited insurers to two nonstandard plan designs per metal level on the ACA marketplaces, with the goal of simplifying the shopping experience for consumers. In the proposed Notice of Benefit and Payment Parameters for the 2027 plan year, released Feb. 9, the CMS said it intends to discontinue those limits as well as requirements that plans offer standardized options on the exchanges. To ease potential disruption, the agency said it will allow payers to choose whether to keep the standardized plan options they currently offer, per a fact sheet. Read Full Article...

HVBA Article Summary

1. Expansion of Plan Design Flexibility: The proposed CMS rule would remove the cap on the number of nonstandard plan designs insurers can offer on ACA exchanges. This change is intended to give insurers more flexibility to innovate and tailor plans to consumer needs. However, it may also result in a wider variety of plan options, potentially making the selection process more complex for consumers.

2. Additional Reforms to Catastrophic and Innovative Plans: The CMS proposal includes allowing catastrophic coverage to be offered for terms longer than one year, up to a decade, and expanding eligibility for such plans to more individuals over age 30. The rule would also permit certain innovative, non-network plans to qualify as ACA-compliant if they meet provider access standards. These changes aim to increase long-term care investment and broaden affordable coverage choices.

3. Strengthened Oversight and Consumer Protections: Alongside increased flexibility, the rule proposes stronger eligibility and income verification for premium subsidies, as well as enhanced enforcement to prevent improper enrollments and unauthorized plan changes. New legal requirements for immigrant eligibility and stricter standards for brokers and agents are also included to deter fraud and misleading marketing. The CMS emphasizes that these measures are designed to protect consumers and ensure that subsidies are distributed appropriately.

Account-based health funding: What benefit leaders should prepare for

By Dana Y. Lujan – Recent statements from the current administration have signaled renewed interest in shifting health care affordability funding toward individual-controlled accounts rather than traditional group insurance structures. Still at the framework stage and requiring legislative action, the concept signals a potential shift in how health care purchasing power flows through the system. Whether or not this specific proposal advances, the direction of travel is already visible. Health care spending authority is moving closer to the individual. When control of dollars shifts, benefit design, risk allocation, and employee engagement models reorganize. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Shift Toward Individual-Controlled Health Funding: The article highlights a growing trend in health care policy and practice, moving from employer-managed group insurance plans to models where individuals control their own health care funds. This shift is driven by both policy discussions and market developments, such as the rise of Health Savings Accounts (HSAs) and benefit wallet technologies. As a result, employees are increasingly expected to act as direct purchasers of care, which changes the dynamics of benefit design and risk allocation.

2. Evolving Role of Employers and Benefit Advisors: As account-based funding mechanisms become more prevalent, employers' roles are transitioning from plan sponsors to strategists who design contribution frameworks and curate care options. Benefit advisors and brokers are also evolving, taking on responsibilities as marketplace architects and employee education partners rather than just negotiating insurance premiums. This evolution requires employers to provide robust decision-support tools and navigation assistance to help employees make informed health care choices.

3. Hybrid Models and the Importance of Preparation: The article emphasizes that while individual control is increasing, employer-sponsored benefit models still offer advantages such as pooled contributions and curated provider networks. The future of health benefits is likely to be a hybrid of defined contributions and curated care ecosystems. Benefit leaders are encouraged to proactively test new contribution models, evaluate care options, and build navigation infrastructure now, rather than waiting for policy mandates, to remain competitive and deliver better employee experiences.

About 60% Adults Qualify for Heart, Renal, or Metabolic Meds

By Archita Rai – About 60% of adults in the US (representing roughly 148 million) met FDA-approved indications for at least one novel cardiovascular-kidney-metabolic (CKM) therapy, most often GLP-1 receptor agonists for weight management; many adults were eligible for more than one drug class. Researchers analyzed national, community-based, and health system data to estimate the proportion of US adults who met current FDA-approved indications for novel CKM therapies. They drew data from a nationally representative US survey (weighted to represent 245 million adults), five pooled community-based longitudinal cohort studies (n = 30,929 adults), and two large ambulatory healthcare system cohorts (n = 447,199 adults). Mean ages of the participants ranged from 46 years to 63 years, and women comprised 52%-61% of the samples. Read Full Article...

HVBA Article Summary

1. High Eligibility for CKM Therapies: The study found that a significant portion of the adult US population meets the criteria for at least one cardiovascular-kidney-metabolic medication, with GLP-1 receptor agonists being the most common due to their use in weight management. This widespread eligibility highlights the growing relevance of these therapies in public health. The findings suggest that many adults may benefit from these medications, but also raise questions about access and implementation.

2. Variation in Eligibility Across Drug Classes and Populations: Eligibility rates differed by medication class and cohort type, with GLP-1 receptor agonists having the highest eligibility, followed by SGLT2 inhibitors and nonsteroidal mineralocorticoid receptor antagonists. The overlap in eligibility for multiple drug classes indicates that some individuals could potentially be prescribed more than one therapy. These differences underscore the importance of individualized patient assessment and careful consideration of clinical guidelines.

3. Study Limitations and Implications for Practice: The authors note that eligibility estimates may be affected by how conditions like chronic kidney disease were measured and that FDA indication does not guarantee a drug is appropriate for every patient. The study's data largely reflect potential eligibility rather than actual prescribing patterns, as baseline information was collected before widespread use of these drugs. The researchers emphasize the need for further studies to address barriers to equitable access and to evaluate real-world outcomes.