Family premiums account for 10% of income in 19 states: Commonwealth Fund

By Paige Minemyer – Middle-income workers and their families are spending an average of 10.1% of the median income on their health premiums and deductibles, according to a new report. The Commonwealth Fund analyzed national data from 2024 on the employer-sponsored insurance market and found that the premium contributions for family coverage ranged from an average of $5,584 in Oregon to $9,148 in California. In 19 states, the average premium and deductible contribution topped 10% of that state's median income. Health insurance costs varied significantly between employers of different sizes and industries, while healthcare costs fluctuated between geographies, contributing to the broad range, according to the study. Read Full Article...

HVBA Article Summary

1. Significant Financial Burden for Families: The report highlights that health insurance premiums and deductibles are consuming a substantial portion of family incomes in many states. This financial strain is particularly pronounced in 19 states where the combined costs exceed 10% of the median income. Such high costs may force families to make difficult choices about their healthcare and other essential expenses.

2. Variation Across States and Employers: The study found considerable differences in premium contributions and deductibles based on geographic location, employer size, and industry. Some states, such as West Virginia, Mississippi, North Carolina, Florida, and Louisiana, have premium contributions alone that surpass the affordability threshold set by the Affordable Care Act. These disparities suggest that where a person lives and works can greatly impact their access to affordable health coverage.

3. Potential Policy and Employer Responses: The report suggests that rising employer premium costs could further increase out-of-pocket expenses for workers, especially if income growth does not keep pace. To address affordability, employers may need to consider adjusting premiums and out-of-pocket requirements based on employee income. Long-term solutions will likely require broader changes in healthcare pricing and spending trends to ensure sustainable coverage for families.

In FTC Settlement, Cigna Agrees to Change Some PBM Business Practices, Charge Customers Less for Insulin

By Luke Sullivan – Cigna has agreed to settle a major federal lawsuit filed against its subsidiary Express Scripts, which alleged it inflated the cost of insulin prices through secretive and nontransparent deals with drug manufacturers. The Federal Trade Commission (FTC) filed lawsuits against the country’s three largest pharmacy benefit managers in 2024, also roping in CVS Caremark and UnitedHealth’s PBM Optum Rx. Cigna was the first of the three to settle and agreed to several demands by the feds. Read Full Article...

HVBA Article Summary

1. Landmark Settlement Targets PBM Practices: The FTC’s settlement with Cigna’s Express Scripts marks the first resolution among lawsuits against the three largest pharmacy benefit managers (PBMs) in the U.S. The agreement requires Cigna to prioritize offering lower-cost drug options to consumers, rather than those yielding higher profits for the PBM. This move is intended to address longstanding criticisms about PBMs’ influence on drug pricing and lack of transparency.

2. Potential for Significant Patient Savings: According to FTC analysis, the settlement could result in substantial savings for patients, particularly those who rely on insulin. The new rules mandate that out-of-pocket costs be based on net drug prices rather than inflated list prices, which could make medications more affordable. The FTC estimates that these changes could save patients billions of dollars over the next decade.

3. Broader Implications for Industry Reform: The settlement introduces structural changes, such as relocating Express Scripts’ purchasing organization from Switzerland to the U.S. and increasing transparency for employer health plans. These reforms are seen by advocates as a potential turning point for PBM regulation, with ongoing negotiations involving other major PBMs. The outcome may set a precedent for future federal oversight and industry practices.

New federal law clashes with DOL proposal over who pays for PBM audits

By Allison Bell – Legislative analysts are sifting through two big new batches of requirements for the pharmacy benefit managers that help employers provide prescription drug benefits. One topic getting attention is the rules that could apply when affected employers or other employer health plan fiduciaries want to audit the PBMs, or find out exactly what PBMs are doing. A team at Foley & Lardner has put the audit rules details in a PBM reform cheat sheet chart. The Foley & Lardner analysis has revealed a conflict between the new PBM audit laws and the draft DOL regulations: Different parties could end up paying for the PBM audits. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Conflict Between Federal Law and DOL Proposal: The new Consolidated Appropriations Act of 2026 (CAA 2026) and the draft Department of Labor (DOL) regulations both address audit rights for pharmacy benefit managers (PBMs), but they differ on who should bear the cost of these audits. While the CAA 2026 prohibits PBMs from paying the auditor, the DOL's draft regulations suggest that PBMs should share the audit costs with health plans. This discrepancy has created uncertainty for employers and PBMs regarding compliance requirements.

2. Implications for Employer Health Plans: The CAA 2026 rules, set to take effect in 2029, will apply to both group and fully insured health plans, granting annual rebate audit rights to plan sponsors and fiduciaries. In contrast, the draft DOL rules would take effect in 2027 and focus on self-insured plans, offering general audit rights but proposing a cost-sharing model. Employers and fiduciaries will need to closely monitor regulatory updates to ensure they meet the correct audit procedures and payment responsibilities.

3. Ongoing Regulatory Process and Stakeholder Input: The DOL is expected to revise its draft regulations to align with the statutory requirements set by Congress. Public comments on the draft regulations are being accepted, allowing stakeholders to influence the final rules. This ongoing process highlights the evolving nature of PBM audit oversight and the importance of staying informed about regulatory changes.

Telehealth use in primary care stabilizes: research

By Emily Olsen – Telehealth use in primary care has held fairly stable in recent years, suggesting the sector has reached an equilibrium after a boom in virtual care amid the COVID-19 pandemic. The boom was supported by new reimbursement and policy flexibilities enacted by the federal government, including changes that allowed for significantly more telehealth coverage in Medicare and virtual prescriptions of controlled substances. However, as the public health emergency wound down, telehealth use declined across specialties, according to previous research from Epic. Mental healthcare remains the biggest area for virtual care, comprising more than 26% of visits in October 2025. Read Full Article...

HVBA Article Summary

1. Stabilization of Telehealth in Primary Care: After an initial surge during the COVID-19 pandemic, telehealth use in primary care has plateaued, maintaining a steady share of total visits since 2023. This suggests that both patients and providers have settled into a new normal, balancing virtual and in-person care. The data indicates that telehealth is now a consistent, though not dominant, component of primary care delivery.

2. Variation in Telehealth Utilization by Demographics: The analysis found that telehealth use is higher among patients in metropolitan areas and among working-age adults, particularly those aged 25 to 39. Children under two and the oldest adults use telehealth at much lower rates. Additionally, patients whose preferred language is not English, especially speakers of Chinese, Portuguese, Russian, Persian, and Spanish, tend to use telehealth more frequently than English speakers.

3. Policy and Access Factors Influence Telehealth Trends: The sustained use of telehealth has been supported by ongoing policy flexibilities, such as extended Medicare coverage for virtual visits. However, barriers remain for certain populations, particularly in rural areas where access to high-speed internet and financial resources for telehealth infrastructure can be limited. The research did not explore patient motivations, but factors like convenience, translation services, and reduced travel likely contribute to telehealth's appeal for specific groups.

HHS restarts 340B rebate pilot work with major call for stakeholder evidence

By Alan Goforth – The U.S. Department of Health and Human Services is seeking feedback from stakeholders on a potential rebate-based model change under the 340B Drug Pricing Program. Earlier this month, following unfavorable court rulings, the agency halted a pilot program that would have changed the way in which rebates are applied. Although discounted prices traditionally have been provided upfront, the pilot program would have required hospitals to provide data to drug manufacturers after certain drugs were dispensed. The Trump administration said this would address drugmaker concerns about abuse and fraud as the number of 340B purchases increases. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Background of the 340B Rebate Pilot: The Department of Health and Human Services (HHS) previously attempted to implement a pilot program that would alter how rebates are processed in the 340B Drug Pricing Program. This initiative was paused after legal challenges from hospital groups, who argued that the changes would impose significant financial burdens on safety-net hospitals. The courts ultimately sided with the hospitals, leading to the suspension of the pilot and prompting HHS to seek broader stakeholder input.

2. Stakeholder Engagement and Evidence Gathering: HHS, through the Health Resources and Services Administration (HRSA), is now actively soliciting feedback from 340B stakeholders to determine the feasibility and design of a potential rebate model. The agency is encouraging stakeholders to provide detailed evidence, research, and data to inform its decision-making process. This approach aims to ensure that any future changes to the rebate system are informed by a wide range of perspectives and factual information.

3. Potential Impact on Hospitals and Timeline: Hospital associations have expressed concerns that a rebate-based model could result in substantial costs for hospitals serving rural and underserved communities. They emphasize the importance of considering the financial impact on these institutions before implementing any changes. HHS has stated that any new rebate program would not take effect until at least 90 days after manufacturer approvals are announced, allowing time for adjustment and further review.

States where people exercise more have lower resting heart rates

By Carly Mallenbaum – Where Americans exercise more, resting heart rates are lower, new Apple data shows. The inverse is also true. Why it matters: A lower resting heart rate is associated with better cardiovascular health and decreased risk of heart disease. What they found: People in D.C., New York, Massachusetts and Vermont recorded some of the most exercise and lowest resting heart rates, per Apple data. Read Full Article...

HVBA Article Summary

1. Correlation Between Exercise and Heart Rate: The Apple Heart and Movement Study found that states where people engage in more physical activity tend to have lower average resting heart rates. This trend was observed across data from over 100,000 Apple Watch users, with adjustments made for age and sex. The findings suggest a strong link between regular exercise and improved cardiovascular health at the population level.

2. Regional Disparities in Heart Health: States such as D.C., New York, Massachusetts, and Vermont reported both higher exercise rates and lower resting heart rates, while Mississippi, West Virginia, Louisiana, Arkansas, and Oklahoma had the opposite pattern. These latter states also have higher rates of heart disease according to CDC data, indicating that regional differences in lifestyle may contribute to broader health outcomes. The data highlights the importance of addressing geographic disparities in physical activity and heart health.

3. Resting Heart Rate as a Health Indicator: Although some states had higher average resting heart rates, these values generally remained within the normal range. The study notes that resting heart rate can be influenced by factors beyond exercise, such as stress, sleep, and diet. Monitoring resting heart rate remains a simple yet effective way for individuals to gauge their cardiovascular health, and increasing physical activity is likely to yield beneficial effects.

AI in healthcare starts long before the exam room

By Guy Benjamin and Dovi Frances – Picture this: An autonomous AI emergency room physician performs a flawless intake, triage and diagnosis of a patient's intense knee pain, cutting wait times by 30%. The patient needs surgery to repair torn tendons. The procedure goes perfectly. They go home thrilled with the experience. Then the $37,000 bill arrives. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Administrative Complexity Remains a Major Barrier: While clinical AI can improve diagnosis and treatment, patients still face significant challenges navigating insurance networks, coverage details, and billing. These administrative hurdles often result in unexpected financial burdens, even when care itself is technologically advanced. Without addressing these systemic issues, the benefits of clinical AI may not translate into better financial outcomes for patients.

2. Navigation-Focused AI Offers Immediate Impact: AI tools designed to help employees identify in-network providers, understand their coverage, and anticipate costs can have a measurable and immediate effect on healthcare experiences. Such solutions face fewer regulatory barriers than clinical AI and can reduce confusion, prevent surprise bills, and improve trust in employer-sponsored health plans. Prioritizing navigation and administrative support could yield greater cost savings and satisfaction than focusing solely on clinical automation.

3. Employers Play a Crucial Role in Healthcare Reform: With roughly 160 million Americans covered by employer-sponsored plans, employers are central to any meaningful healthcare AI strategy. Rising healthcare costs and declining benefit utilization highlight the need for tools that empower employees to make informed decisions before receiving care. Integrating administrative and navigation AI as core infrastructure, as seen in countries like China and Singapore, could help address inefficiencies and improve outcomes for both employers and employees.