PART 2 (Day 2): The Policy Blueprint Communities Are Building for Health Care Transformation

By Dave Chase – Yesterday, I told you about Iowa farmers in 1916 who started building power lines before they even had electricity. That crazy idea sparked the 3-2-1 framework—pioneers prove it, proof spreads, government amplifies—that brought electricity to 90% of rural America. We saw how health care pioneers like Patrick Blackaller in Wisconsin and the Ashtabula County schools in Ohio are proving community-controlled health care works. We watched proof spreading through organizations like the Health Transformation Alliance and Weaver Street Market. Read Full Article...

HVBA Article Summary

1. Historical Blueprint for Health Care Transformation: The article draws a parallel between the rural electrification movement led by Iowa farmers in 1916 and current efforts to transform health care through community-led initiatives. This 3-2-1 framework—where pioneers prove a concept, proof spreads, and government amplifies—has been successfully applied before and is now being used as a model for health care reform. The Indian Self-Determination Act of 1975 is cited as an example where community control improved health outcomes significantly, such as in Alaska Native peoples’ health system.

2. Community-Led Health Care Initiatives and Policy Needs: Successful health care cooperatives and community-owned health plans emerge organically from local needs rather than top-down mandates, contrasting with the failed ACA co-ops. The article advocates for enabling legislation modeled on past successful frameworks like the Rural Electrification Act and the Indian Self-Determination Act. Such legislation would support multi-stakeholder cooperative governance, community-initiated development, and financing for community health plans, accelerating the transformation already underway.

3. Broad Political Appeal and Call to Action: The proposed community health self-determination approach appeals across the political spectrum by emphasizing local control, reduced bureaucracy, universal access, and economic democracy. The article calls on employers, cooperatives, policymakers, and individuals to recognize where value is extracted in their communities and support innovators who are building better health care models. It stresses that policy should amplify community-led proof rather than dictate solutions, encouraging readers to take practical steps and spread awareness.

Employers, pharmacists cheer as Congress finally passes PBM reform

By Paige Minemyer – After years of conversation, legislators pushed key reforms to pharmacy benefit managers over the finish line, much to the chagrin of the industry. Under the bipartisan health funding deal, which was signed into law by President Donald Trump on Tuesday, PBMs will be required to pass through all drug rebates, fees and other funds to the payer, and, if they fail to comply, the Centers for Medicare & Medicaid Services (CMS) can impose fines. In addition, in Medicare Part D, PBM fees must be "delinked" from the list price of drugs. The CMS will also establish reasonable contract terms in Part D around transparency. Read Full Article...

HVBA Article Summary

1. Major PBM Reforms Enacted: The new law requires pharmacy benefit managers (PBMs) to pass all rebates, fees, and related funds directly to payers, with the Centers for Medicare & Medicaid Services (CMS) empowered to fine noncompliant PBMs. Additionally, PBM fees in Medicare Part D must be separated from drug list prices, and CMS will set new transparency standards for contracts. These measures aim to address longstanding concerns about opaque PBM practices and their impact on drug pricing.

2. Mixed Reactions from Stakeholders: While employer groups and pharmacists have welcomed the reforms as a step toward greater transparency and accountability, PBM industry representatives argue that the changes may not lower drug prices as intended. The Pharmaceutical Care Management Association (PCMA) contends that the reforms are the result of a successful lobbying campaign by pharmaceutical manufacturers, who spent record amounts to influence policy. Meanwhile, organizations representing employers and independent pharmacies see the reforms as a critical victory after years of advocacy.

3. Transparency and Competition Expected to Increase: Employer groups believe that increased transparency will help them better understand and manage their healthcare costs, potentially enabling more informed choices among PBMs and health plans. The reforms are also expected to foster competition, particularly among the largest PBMs, by making it easier for employers to compare offerings. However, some stakeholders caution that further reforms may be needed to address broader issues in the pharmaceutical supply chain, including consolidation and data access.

US Health Spending Explained in 5 Charts

By Lawrence Wilson – U.S. health care spending reached $5.3 trillion in 2024, according to recently released data from the Department of Health and Human Services. That includes all health spending through federal and state health programs like Medicare and Medicaid, money paid by individuals to health insurers and providers, spending by employers, and payments made by insurance companies. Here’s a look at the overall picture of America’s health spending and what that means for consumers and taxpayers. Read Full Article...

HVBA Article Summary

1. Unmatched U.S. Health Care Spending Levels Across All Metrics: The United States spends more on health care than any other country globally, whether measured in total dollars, per-capita costs (averaging $15,474 in 2024), or as a share of GDP (18%). Health care is the largest sector of the U.S. economy by both spending and employment. Grouped with social services, it also represents the nation’s largest and fastest-growing source of jobs, surpassing housing, food, and defense in consumer spending share.

2. Spending Growth Driven Primarily by Increased Demand, Not Price Inflation: In 2024, health care spending rose by 7.2%, but health care prices accounted for less than half of that growth. Prices rose just 2.5%—below the general inflation rate of 2.9%. The primary drivers of the increase were greater demand for medical services, higher utilization of health-related goods and services, and population shifts. These findings from the Department of Health and Human Services indicate that overall consumption patterns, rather than price hikes alone, are fueling rising costs.

3. Widespread Public Concern and Policy Divide Over Rising Health Care Costs: Health care accounted for 27% of all federal spending in 2024, with funding largely sourced from individuals through taxes, insurance premiums, out-of-pocket payments, or employer contributions. According to polling by health policy research group KFF, 66% of Americans are worried about affording insurance and medical bills, and 55% report rising costs over the past year. Political approaches differ: Republicans often propose shifting control to consumers through health savings accounts, while Democrats advocate increased regulation and subsidy-based cost controls.

PBM Disclosure Push Intensifies as Congress Acts

By James Van Bramer – Employer health plan sponsors face mounting pressure to scrutinize their pharmacy benefit manager arrangements as Congress passed a set of PBM accountability measures in the latest package of spending bills following a Department of Labor proposed regulation. The recently passed appropriations package, which ended a brief and partial government shutdown, eliminates spread pricing and forces PBMs to disclose how they price prescription drug benefits. The new law is scheduled to take effect in 2028. Read Full Article...

HVBA Article Summary

1. Mandatory Transparency and Reporting Requirements for PBMs: The new law requires Pharmacy Benefit Managers (PBMs) to submit detailed reports to group health plans at least twice a year, with quarterly reporting available upon request. These reports must be provided in both plain language and machine-readable formats and must include pricing information, rebates, fees, alternative discounts, spread pricing structures, and justifications for prioritizing higher-cost drugs over cheaper options. Noncompliance carries steep penalties—$10,000 per day for failure to report and up to $100,000 for each false item submitted.

2. End of Spread Pricing and Required Rebate Pass-Through: The law mandates that PBMs pass all manufacturer rebates directly to plan sponsors, ending a long-standing practice of retaining a portion of those funds. While PBMs may still charge administrative fees, they are now prohibited from engaging in spread pricing—the act of charging health plans more than they reimburse pharmacies and keeping the difference. These changes take effect 30 months after enactment, with most health plans expected to see implementation starting in 2029.

3. Increased Fiduciary Oversight and Sponsor Accountability: A proposed rule by the Department of Labor’s Employee Benefits Security Administration (EBSA) requires PBMs and affiliated providers to disclose actual or estimated dollar amounts of their compensation to plan fiduciaries, replacing previously complex and unclear formulas. Plan sponsors—whether contracting directly with PBMs or through intermediaries like third-party administrators—are still entitled to receive full disclosures and must formally request them if not provided. Legal experts emphasize that receiving disclosures is only the first step, and fiduciaries must establish a process to evaluate whether the information is complete, reasonable, and in line with their responsibilities.

43% of workers are interested in a cash-for-coverage plan concept

By Allison Bell – Many U.S. workers seem to be enthusiastic about the idea of using employer cash to buy their own individual or family health coverage. Researchers from the Employee Benefit Research Institute and Greenwald Research have reported data supporting that possibility in a summary of results from a recent online survey of 1,401 U.S. full-time and part-time workers ages 21 through 64. Much of the survey related to workers' financial wellness and general health insurance access and affordability issues, and much of the media coverage of the survey report has focused on the answers to those questions. But some questions were about what the participants thought about the individual coverage health reimbursement arrangement concept. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Strong Interest in ICHRA Options: The survey found that a significant portion of U.S. workers are open to the idea of employers providing cash for employees to purchase their own health insurance through individual coverage health reimbursement arrangements (ICHRAs). This suggests a shift in employee attitudes toward more flexible health benefits, potentially moving away from traditional group plans. The data indicates that employees may value having greater autonomy in selecting health coverage that best fits their needs.

2. Knowledge Gaps and Survey Methodology: Many workers are not familiar with the specifics of ICHRAs, which could influence their responses to survey questions about these arrangements. To address this, the survey provided participants with a clear description of how ICHRAs work before collecting their opinions. This approach aimed to ensure that respondents' interest levels were based on an informed understanding rather than misconceptions or lack of knowledge.

3. Preference for Choice in Health Plans: The survey also explored workers' preferences regarding the variety of health plan options available through ICHRAs. Nearly half of respondents expressed a preference for having a wide selection of coverage providers and plan types, while a smaller portion favored a more limited set of choices. This highlights the importance employees place on flexibility and customization in their health benefits, which could influence how employers design future benefit offerings.

Pfizer Weight-loss Drug Data Raises Questions About Side Effects, Shares Fall

By Michael Erman and Mrinalika Roy – Pfizer on Tuesday released trial data on a high-profile obesity drug from its recent $10 billion Metsera purchase that raises questions about its tolerability for patients, and shares of the U.S. drugmaker fell more than 3%. The drug, given as a monthly ‌injection, showed sustained weight loss at 28 weeks, Pfizer said, adding that it is targeting 2028 for its first approval in the fast-growing weight-loss drug market. The company made the disclosure alongside reporting fourth-quarter earnings, which beat Wall Street estimates. Read Full Article...

HVBA Article Summary

1. Efficacy and Discontinuation Concerns: Pfizer's new obesity drug, acquired through the Metsera purchase, demonstrated promising weight loss results in a mid-stage trial, with no plateau observed at 28 weeks. However, about 10% of patients discontinued the trial due to adverse side effects, raising concerns about the drug's tolerability. The dropout rate is similar to other drugs in the GLP-1 class, but there is uncertainty about whether this rate will increase over a longer period or at higher doses.

2. Market Strategy and Competitive Landscape: Pfizer is positioning itself to compete in the rapidly expanding obesity drug market, which is projected to be worth $150 billion. The company is not currently worried about price competition, even as other major players like Novo Nordisk have warned of potential profit and sales declines due to pricing pressures. Pfizer plans to advance over 20 clinical trials in obesity treatments this year, aiming to offset revenue losses from older drugs facing generic competition.

3. Financial Performance and Future Outlook: Despite concerns about the new drug's side effects, Pfizer reported strong fourth-quarter earnings, surpassing Wall Street expectations in both sales and profit. The company reaffirmed its 2026 revenue and earnings forecasts, reflecting anticipated impacts from drug pricing agreements. Pfizer is relying on the success of new drugs, including those for obesity, to drive a return to revenue growth, which it does not expect until 2029.

Novo, Lilly sputter as Hims launches knockoff GLP-1 pill

By Ben Fidler – Hims & Hers Health is launching a copycat form of Novo Nordisk’s newly launched obesity pill, ushering in the latest contentious battle between the makers of branded weight loss medications and their drug-compounding counterparts. Hims said Thursday that it’s now enabling healthcare providers to prescribe a compounded pill with the same active ingredient, semaglutide, as Novo Nordisk’s oral Wegovy. That treatment will be sold as part of treatment plans that begin at $49 for the first month — $100 lower than the price Novo is charging under a deal with the Trump administration. Hims also claimed that its treatment is formulated differently and involves a different delivery method to protect the active ingredient during digestion. Read Full Article...

HVBA Article Summary

1. Legal and Safety Concerns Raised by Novo Nordisk: Novo Nordisk has condemned Hims & Hers' launch of a compounded version of its Wegovy pill, calling it "illegal mass compounding and deceptive advertising." Novo claims the compounded drug is unapproved, inauthentic, and untested, posing significant risks to patient safety. The company has threatened legal and regulatory action to protect its intellectual property and uphold drug approval standards in the U.S.

2. FDA's Stance on Copycat Drugs: FDA commissioner Martin Makary warned that the agency will take swift action against companies mass-marketing illegal copycat drugs that claim similarity to FDA-approved products. The FDA cannot verify the quality, safety, or effectiveness of such non-approved drugs, highlighting regulatory concerns about compounded versions of branded medications.

3. Market Impact and Competition: The presence of drug compounders like Hims & Hers has affected Novo Nordisk's market share, which has declined partly due to competitive pressures including compounded drugs. Novo's oral Wegovy pill had a record-fast launch, but Hims' lower-priced compounded alternative has caused stock declines for both Novo and Lilly. Analysts note uncertainties about the compounded drug's absorption and side effects, while Lilly continues to outperform expectations despite competition.