Private Insurance is Seeping Into Every Public Health Program: Warning Signs From the Veterans Health Administration

By Rachel Madley, PhD – It is widely known that private insurance companies play a major role in Affordable Care Act health plans and public health programs like Medicare and Medicaid. Far less understood is that private insurance is now steadily creeping into the Veterans Health Administration (VHA) through the Veterans Community Care Program (VCCP). Created under the 2018 VA MISSION Act, the VCCP relies on private contractors to build provider networks and administer payments for veterans receiving care outside the VA. The proposed expansion of this program — Community Care Network (CCN) Next Generation – would scale this model to as much as $1 trillion over the next decade without addressing serious, well-documented failures in the current system. Read Full Article...

HVBA Article Summary

1. Expansion of Private Insurance in the VA: The article highlights how private insurance companies are increasingly involved in the Veterans Health Administration through programs like the Veterans Community Care Program and its proposed expansion, the Community Care Network Next Generation. This shift is part of a broader trend where private insurers become intermediaries in public health programs, collecting taxpayer funds while influencing care delivery. The author warns that this model may undermine the effectiveness of public health systems by prioritizing profit over patient care.

2. Concerns Over Conflicts of Interest and Oversight: There are significant concerns about conflicts of interest, particularly with contractors like OptumServe, whose parent company owns a large number of clinical organizations. The lack of publicly available data makes it difficult to assess whether veterans are being steered toward affiliated providers. Congressional hearings have revealed that VA officials have not provided clear answers about safeguards or oversight mechanisms to prevent such conflicts, raising questions about transparency and accountability.

3. Potential Risks to Quality and Cost of Care: Research cited in the article suggests that VA-provided care often outperforms private-sector care in terms of efficiency, outcomes, and administrative costs. The expansion of private insurance models into veterans' care could import problematic features from other programs, such as value-based payment systems and risk adjustment mechanisms that have led to overpayments and care denials in Medicare Advantage. Lawmakers and the author argue that without addressing these flaws, the expansion could result in higher costs and diminished care quality for veterans.

Congress' push to rein in drug costs will impact benefit strategies

By Alyssa Place – As prescription drug spending continues to climb, employer groups are pressing lawmakers to go beyond surface-level reforms and address structural inefficiencies embedded throughout the drug supply chain. Testifying before the House Energy and Commerce Subcommittee on Health, James Gelfand, president and CEO of The ERISA Industry Committee (ERIC), emphasized that employer-sponsored coverage — which insures more than 150 million Americans — remains the largest source of private health insurance in the U.S., and is increasingly burdened by rising pharmacy costs. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Comprehensive Reform Needed Beyond PBMs: Gelfand highlighted that while PBM reform is a step in the right direction, it is insufficient on its own to resolve the complex issue of drug affordability. He urged lawmakers to take a broader view of the healthcare ecosystem, focusing on systemic problems such as misaligned financial incentives, lack of market competition, and the overall opacity in the pharmaceutical supply chain that contribute to rising costs for both employers and patients.

2. Transparency and Accountability as Strategic Tools: Greater transparency, enhanced reporting, and expanded data access were presented as essential tools to improve employer oversight of healthcare spending. Gelfand emphasized that these reforms would empower benefit leaders to conduct stronger audits, negotiate more favorable terms with vendors, and ensure that health plans are delivering the best possible value to employees. Congressional action to boost accountability is seen as key to advancing these efforts.

3. Encouraging Market Competition and Flexibility: Legislative proposals discussed in the hearing aim to increase fairness in healthcare contracting, such as enabling employers to steer employees toward high-quality, lower-cost providers and contract directly with hospitals without being restricted by network limitations. These policy changes align with current challenges faced by benefit managers, who are already adopting strategies like reassessing PBM contracts, promoting biosimilars, using advanced analytics, and exploring value-based purchasing to reduce costs and improve care quality.

PBM trade group demands supply chain transparency for all

By Allison Bell – The new chief executive officer of the pharmacy benefit managers' trade group — the Pharmaceutical Care Management Association — testified at a House hearing in Washington Wednesday that Congress should impose tough transparency requirements on all players in the U.S. drug supply chain, not just on the PBMs. David Marin, a former drug manufacturer government affairs executive who took over as the PCMA CEO in January, told members of the House Energy & Commerce Committee's Health Subcommittee that PBMs accept the need for more price transparency. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Call for Broader Transparency: David Marin, CEO of the Pharmaceutical Care Management Association, argued that transparency mandates should not be limited to pharmacy benefit managers (PBMs) but should extend to all entities in the drug supply chain. He emphasized that manufacturers and wholesalers also play significant roles in drug pricing and should be subject to the same scrutiny. Marin believes that applying transparency requirements across the board would better address affordability and competition issues in the pharmaceutical market.

2. Concerns Over Current Legislation: Marin expressed reservations about the new federal PBM transparency laws, stating that while PBMs are prepared to comply, the laws may be unnecessary and could potentially hinder efforts to make drugs more affordable. He pointed out that the legislation places a heavy reporting burden on PBMs without similar obligations for other supply chain participants. According to Marin, this selective approach could limit the effectiveness of transparency initiatives in achieving lower drug prices.

3. Employer and Industry Perspectives: Testimony from James Gelfand of the ERISA Industry Committee highlighted ongoing challenges employers face in obtaining data from PBMs, with a significant portion unable to access needed information. Gelfand also noted that PBMs and wholesalers collectively capture a substantial share of prescription drug spending, raising concerns about self-dealing and conflicts of interest. These perspectives suggest that transparency issues are widespread and not confined to PBMs alone, reinforcing calls for broader regulatory oversight.

Ripple effects of Medicare Advantage rate freeze

By Maya Goldman – The Trump administration's surprise decision to freeze payments to private Medicare plans is likely to supercharge tensions between physicians and insurers and create new barriers to senior care. Why it matters: Limiting revenue in a core business for major health insurers will set off a chain reaction that ultimately affects the more than 34 million beneficiaries in Medicare Advantage plans. Read Full Article...

HVBA Article Summary

1. Impact on Providers and Patients: The proposed freeze on Medicare Advantage payments is expected to strain relationships between insurers and healthcare providers. Physicians and hospitals may face lower reimbursements and increased administrative hurdles, such as more prior authorization requirements. This could result in some providers leaving Medicare Advantage networks, potentially reducing access to care for seniors.

2. Industry and Policy Reactions: The rate freeze proposal has alarmed insurers and investors, as it diverges sharply from previous years' increases and may not keep pace with rising medical costs. Insurers argue that the change could make it harder to maintain low premiums and supplemental benefits for enrollees. Meanwhile, some policy experts and patient advocates support the move, viewing it as a necessary correction to address perceived overpayments to Medicare Advantage plans.

3. Uncertain Future and Political Considerations: The final decision on 2027 Medicare Advantage payments is expected in early April, and political factors, such as the upcoming midterm elections, may influence the outcome. There is a possibility that the administration could adjust the proposal in response to public feedback or concerns about service reductions for seniors. The situation remains fluid, with stakeholders closely watching for potential changes in the finalized policy.

Colorectal cancer is rising in younger adults. Here’s who is most at risk and symptoms to watch for

By Lauran Neergaard – Colorectal cancer is a threat not just to older adults but increasingly to young men and women, too. It’s now the top cancer killer of Americans younger than 50. The deaths of “Dawson’s Creek” actor James Van Der Beek at 48 this week, and a few years ago “Black Panther” star Chadwick Boseman at 43, highlight the risk for younger adults. “We’re now starting to see more and more people in the 20-, 30- and 40-year-old range developing colon cancer. At the beginning of my career, nobody that age had colorectal cancer,” said Dr. John Marshall of Georgetown University’s Lombardi Comprehensive Cancer Center, who has been a cancer doctor for more than three decades. Read Full Article...

HVBA Article Summary

1. Rising Incidence Among Younger Adults: Colorectal cancer, once considered a disease primarily affecting older adults, is increasingly being diagnosed in people under 50. This trend is notable because it contrasts with the overall decline in cases and deaths among older populations, likely due to improved screening. The rise in younger cases has made colorectal cancer the leading cancer killer for Americans under 50, prompting concern among medical professionals.

2. Risk Factors and Prevention: While most cases still occur in those over 50, younger adults are not immune, and many do not have traditional risk factors. Factors such as obesity, low physical activity, diets high in red or processed meats, smoking, heavy alcohol use, inflammatory bowel disease, and family history can all increase risk. Experts recommend a diet rich in fruits, vegetables, and whole grains, along with regular exercise, as preventive measures for people of all ages.

3. Screening and Early Detection: Medical guidelines advise beginning colorectal cancer screening at age 45 for average-risk individuals, but some may need to start earlier based on personal or family history. Early detection is crucial, as survival rates are significantly higher when the disease is found before it spreads. Symptoms such as blood in stool, changes in bowel habits, unexplained weight loss, and abdominal pain should not be ignored, and prompt medical evaluation is recommended.

How the generative AI boom changes healthcare cybersecurity

By Emily Olsen – Generative artificial intelligence has exploded in the healthcare sector in recent years, driven by hopes the technology could take on a variety of tasks — from clinical documentation to data analysis — and lessen the industry’s long-standing workforce challenges. At the same time, healthcare organizations often struggle to manage cybersecurity, burdened by frequent cyberattack attempts as the sector adopts more internet-connected tools. Read Full Article...

HVBA Article Summary

1. AI Introduces New Cybersecurity Risks: The integration of generative AI tools into healthcare systems brings novel cybersecurity vulnerabilities. These tools can be manipulated by attackers in subtle ways, such as introducing hidden functionality or influencing outputs, making it difficult to detect tampering or errors. As AI systems evolve from static models to autonomous agents, healthcare organizations must develop end-to-end visibility into the models’ origins, training data, deployment methods, and outputs. This transparency is critical for identifying and managing risks effectively.

2. Healthcare Cybersecurity Requires New Roles and Governance Models: The growing complexity of AI in healthcare necessitates the creation of new cybersecurity roles and skill sets. Organizations must adopt practices such as AI “red teaming” — intentionally stress-testing AI models to find vulnerabilities — and implement strict identity controls to distinguish between users and AI agents. There is also an emerging need for AI governance professionals who not only understand how AI systems are built and operate, but also grasp the regulatory, clinical, and business contexts in which they function. This blend of expertise is vital for assessing and mitigating AI-related risks.

3. AI Accelerates the Speed and Sophistication of Cyberattacks: As threat actors begin using AI to enhance and automate their attacks, the pace at which cybersecurity teams must respond is rapidly increasing. Traditional incident response times measured in hours are no longer sufficient; responses may now need to occur within seconds or milliseconds. Healthcare organizations should focus on building flexible, responsive systems — with capabilities to detect, patch, and recover quickly — and prioritize identity management as a foundational element for applying context-aware security controls across both human and machine agents.

Kaiser reaches settlement with DOL over alleged mental healthcare access failures

By Ginger Christ – At issue are alleged violations of federal mental health parity laws, Kaiser said. The Mental Health Parity and Addiction Equity Act requires health plans to cover mental health and substance use disorders in a comparable way to medical and surgical benefits, per DOL. The act requires that financial requirements such as copays and deductibles as well as yearly visit limits, prior authorization requirements and proof of medical necessity are similar. Read Full Article...

HVBA Article Summary

1. Settlement Details and Allegations: Kaiser Foundation Health Plan agreed to reimburse over $28 million to eligible members in California as part of a settlement with the U.S. Department of Labor. The DOL alleged that Kaiser failed to provide timely and appropriate access to mental health and substance use disorder services by not maintaining adequate provider networks and using patient questionnaires to restrict care access. This forced members to seek out-of-network care, often incurring higher out-of-pocket costs. The settlement applies to care received between January 2021 and September 2024 and does not reflect current practices.

2. Mental Health Parity and Contributing Factors: The case involves alleged violations of the Mental Health Parity and Addiction Equity Act, which mandates that mental health and substance use disorder benefits be covered comparably to medical and surgical benefits. Kaiser attributed some challenges to increased demand for mental healthcare since the COVID-19 pandemic, which has led to a shortage of qualified professionals and clinician burnout. Kaiser acknowledged difficulties in providing consistent access during this period but stated that investments made have improved access significantly.

3. Additional Settlement Terms and Workforce Context: Besides member reimbursements, Kaiser will pay nearly $3 million to the federal government and implement policy reforms to improve care access, including reducing wait times and monitoring network adequacy. The company has faced multiple strikes by mental health workers in recent years over staffing levels, pay, and workloads, highlighting ongoing workforce challenges. These labor actions underscore the broader context of staffing shortages impacting mental healthcare delivery within Kaiser Permanente.