TPAs: The Goodfellas Running Employers’ Health Plans

By David Himmel – The 119th Congress headed into the holidays no doubt looking forward to quality time with their loved ones and a fat goose on the dinner table—or whatever the privileged stewards of the People eat at Christmas—with what seemed like little concern for the mess and panic they left behind. Messy panic like what the nearly 25 million Americans getting their health insurance through the ACA are facing as their monthly premiums increase at astronomical rates. (Assuming they stick with the devil they know.) Now they’re back, surely refreshed with all engines blazing on their New Year’s resolution to make health care more affordable. It is, after all, what the People want. Read Full Article...

HVBA Article Summary

Editor’s Note: This article shines light on what is happening in the BUCA TPA space primarily. At the HVBA, we are proud to partner with transparent TPAs across the country who are building a better model and serving our employers and members with integrity and honesty.

1. Self-Insured Employers Are Vulnerable to Hidden Abuses by TPAs: Although self-insurance is intended to offer employers more control over health plan design, cost management, and access to claims data, many companies unknowingly lose that control after outsourcing administration to third-party administrators (TPAs). Approximately 57% of private sector workers in the U.S. are enrolled in self-funded health plans, yet TPAs—often subsidiaries of major insurers known collectively as the BUCAs (Blue Cross Blue Shield, UnitedHealthcare, Cigna, and Aetna)—frequently operate with little transparency. Through administrative services agreements (ASAs), TPAs embed gag clauses and assert that claims data is “proprietary,” limiting employer oversight of their own health plan spending. This lack of visibility undermines the core purpose of self-funding.

2. TPA Fee Structures Can Encourage Cost Inflation and Conflict of Interest: TPAs implement questionable financial practices that directly profit from errors or cost reductions, creating perverse incentives. For example, in “overpayment recoupment” scenarios, TPAs may recover funds from providers due to billing errors and then keep around 30% of the recovered amount as a fee—effectively charging employers extra for mistakes often caused by the TPAs themselves. In another case, TPAs negotiate down expensive out-of-network claims (e.g., from $50,000 to $20,000) and pocket roughly 30% of the “savings,” or $9,000 in this example. Employers are often unaware of these transactions because they are shielded under “proprietary” agreements. These arrangements can lead to increased use of out-of-network services and lack of financial accountability.

3. Legislative Solutions Are Proposed, but Enforcement and Impact Remain Uncertain: The Patients Deserve Price Tags Act (PDPTA), introduced in 2023 by Senators Hickenlooper (D-Colo.) and Marshall (R-Kan.), aims to enforce transparency and accountability among TPAs. It would ban restrictive ASA provisions, require TPAs to report compensation and rebate details quarterly, and authorize the Department of Labor to issue fines—$10,000 per day for access violations and $100,000 per day for failing to report financial data. While this bill seeks to close existing loopholes left by earlier laws like ERISA and the 2021 Consolidated Appropriations Act, the article questions whether it will survive lobbying pressure from the BUCAs or actually reduce costs for self-insured employers, since TPAs can simply raise fees in response to regulatory changes.

SIIA Government Relations Update 1.9.2026

By SIIA – In our December Newsletter (which you can find here), we told you that the smart money in DC was always betting that Republicans and Democrats would fail to agree on a compromise bill to extend the ACA’s “enhanced premium subsidies” before the December 31st deadline. That was the right bet, as the “enhanced premium subsidies” officially expired at midnight on New Year’s Eve. Read Full Article...

HVBA Article Summary

1. House Passes ACA Subsidy Extension, but Senate Path Remains Unclear: In late 2025, the House passed a 3-year extension of the enhanced Affordable Care Act (ACA) premium subsidies, with full Democratic support and 17 Republicans voting in favor. While this move signals bipartisan concern over healthcare affordability, the extension is not expected to move forward in the Senate without additional negotiations, leaving the policy's future uncertain.

2. Senate Republicans Explore Compromise, Dependent on Trump and Policy Concessions: A group of Senate Republicans has begun developing a potential compromise to temporarily extend the enhanced subsidies, but their efforts hinge on two major factors: strong backing from former President Trump and the inclusion of conservative-leaning policy provisions such as Association Health Plans (AHPs), Health Savings Accounts (HSAs), and Individual Coverage Health Reimbursement Arrangements (ICHRAs). Without these elements, the proposal may face significant resistance in the House.

3. Federal Agencies Propose Key Reforms to Improve Health Price Transparency: In response to years of industry feedback, federal departments released proposed changes to Transparency in Coverage (TiC) regulations just before the 2025 holidays. The reforms aim to improve the accuracy, organization, and usability of machine-readable files (MRFs) that disclose in-network and out-of-network medical pricing. Proposed updates include eliminating misleading "ghost rates," lowering the threshold for disclosing out-of-network payments, and adding new contextual files (e.g., change logs, utilization data) to enhance public understanding. Final regulations are expected no earlier than Q3 2026.

Trump says he may veto extension of Obamacare subsidies

By Julie Steenhuysen – U.S. President Donald Trump said on Sunday he might veto legislation to extend federal health insurance subsidies, injecting fresh uncertainty into a debate that has pitted congressional Republicans against Democrats and threatened to raise premiums for millions of Americans. Expiration of the health insurance tax breaks at the end of 2025 left millions of Americans facing significant price hikes for coverage. Read Full Article...

HVBA Article Summary

1. House Passage of ACA Subsidy Bill: The Republican-led U.S. House of Representatives passed legislation aimed at restoring federal subsidies for the Affordable Care Act (ACA), a measure originally backed by Democrats. Notably, 17 Republican lawmakers crossed party lines to support the bill, indicating some bipartisan agreement on the issue.

2. Senate Rejection and Possibility of Compromise: Although a similar version of the bill has already been rejected by the Republican-controlled Senate, the House’s approval may open the door for renewed discussions and potentially lead to a bipartisan compromise on healthcare funding and reform.

3. Enrollment Deadline for ACA Coverage: The current deadline for Americans to sign up for ACA health insurance coverage is January 15. However, the Trump administration has the discretion to extend this deadline, which could impact enrollment numbers and access to healthcare coverage.

Shifting from term life insurance to whole life

By Abbie Rodriguez – In the first quarter of 2025, whole life insurance held 37% of the total new annualized premiums sold, while term life slipped 1% to 19% of the market, according to data from LIMRA. However, some people may first approach the life insurance industry with the purchase of a term life policy, often when making a specific life change like getting married, having children or buying a house. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Term Life Insurance Offers Affordable, Temporary Coverage for Key Financial Milestones: Term life insurance provides cost-effective protection during financially demanding phases, such as paying off a mortgage or raising children. With premiums as low as $20 per month, it's ideal for younger individuals or couples with short- to mid-term financial obligations. In the case of Alex and Jill, a couple in their early 30s, a 30-year, $300,000 term policy aligned with their mortgage and gave them peace of mind while they rebuilt savings and raised a family.

2. Whole Life Insurance Enables Lifetime Coverage and Wealth Planning Advantages: Whole life insurance remains in effect for the policyholder’s entire life and includes a cash value component that builds over time. This makes it a strategic choice for estate planning and long-term financial security. Though it carries higher premiums, whole life can be used to support future generations or cover final expenses. As Alex and Jill's income grew and their financial responsibilities shrank, whole life became a more suitable option for leaving a legacy and securing permanent protection.

3. Converting Term to Whole Life Can Be a Strategic Move in Later Life Stages: Transitioning from term to whole life insurance can be seamless when done during a policy’s conversion window, especially without requiring new medical underwriting. For Alex and Jill, now in their early 50s and in good health, converting $100,000 of their original $300,000 term policy allowed them to lock in lifelong rates while shifting their focus from financial protection to estate planning. Partial conversion also offers flexibility—preserving affordability while providing lasting coverage aligned with new goals.

Industry shifts 6 CEOs say leaders are underestimating for 2026

By Kristin Kuchno – In 2025, hospital and health system CEOs navigated regulatory changes, workforce shortages and financial strain. Many reported increased burnout, and others noted the role has evolved in several ways, including a more public-facing nature and a greater focus on workforce engagement. Read Full Article...

HVBA Article Summary

1. AI Is Becoming Core Infrastructure in Healthcare: Multiple CEOs emphasized that artificial intelligence is rapidly shifting from pilot projects to essential infrastructure. Leaders like Johnese Spisso (UCLA Health) and Dipen Parekh (University of Miami Health System) stress that AI’s potential to improve outcomes, reduce clinician burden, and enhance operations is being underestimated. Those who fully integrate AI across systems—not just experiment with it—will gain competitive and clinical advantages by 2026.

2. Generational Workforce Shifts Require Tailored Strategies: CEOs highlighted that health systems may be underestimating the impact of generational changes in the healthcare workforce. Richard Lofgren (OU Health) emphasized the need for differentiated workforce strategies to accommodate varying generational expectations, while Terry Murphy (Bayhealth) underscored the growing care demands of an aging baby boomer population, which will require more senior-focused care delivery models.

3. State-Level Policy and Operational Discipline Are Critical Yet Overlooked: Health system leaders warned that state legislation and operational discipline are undervalued strategic concerns. Terry Murphy noted that state governments are taking more aggressive stances toward hospitals, necessitating proactive engagement and transparency. Meanwhile, Colin McHugh (Southern New Hampshire Health) stressed that tighter resource management, frontline engagement, and addressing burnout through disciplined operations are essential for sustaining high-quality care.

As health costs rise, Americans put more money in HSAs

By Jimmy Nesbitt – Americans are putting more money into health savings accounts amid historic premium increases and rising out-of-pocket expenses. New data from HSA provider Lively shows that the average account balance for the company's clients was $5,457 in 2025 compared to an average of $4,923 last year. That's a year-over-year increase of 11%.. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. HSA Utilization Is Growing, but Education Gaps Persist: Health Savings Accounts (HSAs) are increasingly seen as a powerful tool for managing healthcare costs, with investment assets reaching nearly $73 billion by midyear 2025, marking a 30% year-over-year increase, according to a Devenir survey. However, employee education remains the primary barrier to full utilization. Many workers take a reactive approach to benefits, often engaging only during emergencies or open enrollment periods. Confusion over similar-sounding programs like HSAs, FSAs, and HRAs can lead to inaction, limiting the potential long-term savings these accounts can provide.

2. Employer Contributions Boost Participation and Support Equity: Companies that make one-time or recurring contributions to employee HSAs report significantly higher participation rates. These contributions not only encourage more employees to engage with their accounts but also serve as an effective retention strategy. Furthermore, while higher-income earners are more likely to max out their HSA contributions, employer funding can help "level the playing field" for lower-income workers. Some employers are even contributing more to employees in vulnerable financial situations, aiming to increase access to healthcare savings regardless of income level.

3. Policy Changes Are Expanding HSA Access and Strategic Importance: Recent federal legislation — specifically the One Big Beautiful Bill Act — has expanded HSA eligibility to include Bronze and Catastrophic ACA plans, and now allows direct primary care fees to be paid with HSA funds. These changes are driving broader adoption, and benefits leaders increasingly view HSAs as a "core cornerstone" of their benefits and financial wellness strategies. Some experts, like Shobin Uralil, advocate for removing the high-deductible health plan (HDHP) requirement altogether to allow more Americans to save and pay for healthcare through HSAs on their own terms.

Lilly’s Zepbound Plus Taltz Boosts Arthritis Relief, Weight Loss in Late-stage Trial

By Mariam Sunny – Eli Lilly said on Thursday a late-stage trial showed its weight-loss drug Zepbound, used with ‌its psoriatic arthritis treatment Taltz, improved arthritis symptoms and drove weight loss better than Taltz alone. Lilly ⁠said 31.7% of patients who received Taltz plus Zepbound met the main goal of ‌the study: at least a 50% reduction in psoriatic arthritis disease activity and at least 10% weight loss after 36 weeks. That compared with 0.8% of patients who took Taltz alone and met the same combined outcome. Read Full Article...

HVBA Article Summary

1. Study Results Show Enhanced Efficacy With Combination Therapy: A clinical trial involving 271 overweight or obese adults with active psoriatic arthritis found that 33.5% of those treated with a combination of Taltz and Zepbound achieved at least a 50% reduction in disease activity. This compares to 20.4% of participants who received Taltz alone, indicating that the dual therapy may offer greater improvements in managing the condition.

2. Potential Benefits for a Common Patient Subgroup: Eli Lilly noted that about 65% of U.S. adults with psoriatic arthritis are either overweight or obese and also have at least one other weight-related health issue. This highlights the potential value of a treatment approach that addresses both inflammation and weight-related factors for a large portion of the patient population.

3. Side Effects and Considerations: While the combination therapy showed improved outcomes, it was also associated with gastrointestinal side effects. The most commonly reported were nausea, diarrhea, and constipation, each occurring in at least 5% of patients. These side effects are important to weigh when considering the overall benefit-risk profile of the treatment.