Anthem CEO Could Face Tough Questions From Lawmakers This Week

By Wendell Potter – Only in America do patients have to worry about whether the doctors who treat them when they’re in the hospital might not be in their insurance company’s provider network – even though their hospital is in network. In fact, in very few if any other countries do patients have to worry about networks at all. (Fortunately, American seniors enrolled in traditional Medicare don’t have that worry either because, unlike private Medicare Advantage plans, employer-sponsored and Obamacare marketplace plans, traditional Medicare doesn’t even have networks). Read Full Article...

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1. Anthem’s Policy Change Pressures Hospitals and May Lead to Higher Costs: Starting January 1, Anthem (owned by Elevance Health) implemented a policy that reduces payments to hospitals if they allow out-of-network doctors to treat Anthem-covered patients. This move forces hospitals to track constantly changing insurer networks more closely, which may increase administrative burden and costs. Hospitals might respond by raising prices to compensate for the reduced reimbursements and added complexity.

2. Legislative Scrutiny Intensifies Amidst Rising Premiums and Profits: Insurance executives, including Elevance CEO Gail Boudreaux, are set to testify before Congress about escalating insurance premiums despite the industry’s high profits. The hearings coincide with ad campaigns by the insurance industry blaming hospitals for rising healthcare costs. Lawmakers, such as Rep. Greg Murphy, are expected to question insurers’ practices and push for greater accountability under the No Surprises Act (NSA).

3. Proposed Legislation Seeks to Close Loopholes in the No Surprises Act: A bipartisan bill titled the No Surprises Act Enforcement Act aims to close a loophole that currently exempts insurers from financial penalties when they violate NSA provisions. The bill would impose fines and late-payment penalties on insurers who fail to pay or delay payment after arbitration rulings. Supporters argue the law is necessary because insurers have allegedly exploited the loophole, potentially leaving patients vulnerable to significant out-of-pocket costs.

House Appropriations Committee releases health funding proposal

By Paige Minemyer – The House Appropriations Committee has unveiled proposed outlays for the Department of Health and Human Services (HHS), including key investments in priorities within the Make America Healthy Again movement. The bill would include $116.6 billion in discretionary funding for the HHS and reduces spending on "federal bureaucracy" at the agency by $100 million, according to a fact sheet (PDF) from the committee. Read Full Article...

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1. Policy and Oversight Enhancements in Healthcare: The legislative proposal introduces a range of policy reforms aimed at increasing transparency and accountability in the healthcare system. It targets pharmacy benefit managers by introducing flat service fees, addresses “ghost networks” in Medicare Advantage by requiring accurate provider directories, and mandates unique identification numbers for outpatient services to allow for better pricing transparency. These changes are positioned to support broader reforms, including a shift toward site-neutral payments—an approach that has faced opposition from parts of the hospital industry.

2. Continued and Expanded Healthcare Funding: The package maintains and expands funding across multiple healthcare sectors. It includes $418 million for rural healthcare, $1.9 billion for community health centers, $1.4 billion to support and connect healthcare workers with underserved areas, and $1.2 billion for maternal and child health programs. It also provides $49 billion to the National Institutes of Health (NIH) to advance research on critical health priorities such as cancer, Alzheimer’s disease, diabetes, rare diseases, and other chronic conditions affecting Americans. In addition, it extends several telehealth and virtual care programs—such as hospital-at-home waivers through 2030 and other telehealth flexibilities through 2027—highlighting sustained bipartisan support for digital health access.

3. Notable Omissions and Political Context: While the proposal enjoys bipartisan support, it omits several high-profile healthcare cost issues. Notably, it does not address the expiration of the Affordable Care Act’s enhanced subsidies, which lapsed on January 1 and are contributing to rising insurance premiums. It also does not include provisions from the White House’s “Great Healthcare Plan.” The bill proposes eliminating the CDC’s social determinants of health initiatives, labeling them as distracting from core public health goals. Lawmakers from both parties have expressed support for the proposal overall, with Republicans highlighting fiscal discipline and Democrats emphasizing the preservation of key federal health programs, despite some ideological divides reflected in the package’s exclusions.

Congress pushes back against Trump's NIH cuts

By Peter Sullivan – Republicans and Democrats are using the latest government funding package to push back against President Trump's proposed cuts to the National Institutes of Health — and limit the administration's influence over biomedical research grants. Why it matters: The bipartisan sentiment shows that medical research and efforts to find new cures still have strong support on Capitol Hill after a turbulent year for NIH. Read Full Article...

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1. Significant Boost in NIH Funding Despite Proposed Cuts: The health care section of the newly released spending package provides $48.7 billion in funding for the National Institutes of Health (NIH) — an increase of $415 million over the previous year. This allocation stands in stark contrast to President Trump’s proposed 40% budget cut for the NIH, signaling a strong bipartisan commitment to continued investment in medical research. Lawmakers appear to be prioritizing long-term health initiatives despite executive branch opposition.

2. Pushback Against Trump-Era Grant Funding Policies and Overhead Caps: The bill includes language aimed at limiting a policy from the Trump administration that awarded funding for the full duration of research grants in a single payment. Critics of the policy argued it reduced the overall number of grant awards made by NIH. Additionally, the spending package preserves a provision blocking NIH from imposing a 15% cap on administrative and overhead costs, a restriction that many believe would slow scientific breakthroughs and financially burden research institutions, especially major universities.

3. Restoration of Rare Pediatric Disease Treatment Program: Outside of NIH-specific funding, the package also revives a key program that gives priority review to treatments for rare pediatric diseases — a program that had expired at the end of 2024 and was notably excluded from follow-up funding measures. Its inclusion in the new bill marks a renewed emphasis on addressing unmet medical needs in vulnerable pediatric populations through expedited regulatory pathways.

Exclusive: HHS watchdog finds $19B in waste, fraud and savings

By Maya Goldman – The government's health care watchdog identified more than $19 billion in wasteful or fraudulent federal payments and possible cost savings during a span that included the first nine months of President Trump's second term, a report provided exclusively to Axios shows. Why it matters: The Trump administration often cites rampant waste, fraud and abuse as justification for deep program cuts. Read Full Article...

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1. Surge in Medicare Spending on Skin Substitutes and Response: The Department of Health and Human Services' (HHS) Office of Inspector General (OIG) reported a dramatic 640% increase in Medicare payments for high-tech skin substitutes compared to the previous year. In response, Medicare administrators implemented a new cap on reimbursement for these bioengineered grafts in the fall, a move projected to save over $9 billion. The OIG has committed to ongoing monitoring in the upcoming year to ensure that the policy change is effective and that Medicare funds are protected from excessive or inappropriate spending.

2. Record Savings Driven by Timing of Legal Outcomes: The semiannual report for fiscal year 2025 highlighted significantly higher financial recoveries than the $7 billion reported in 2024. However, the inspector general’s office clarified that much of the increase is due to the timing of finalized civil settlements and criminal judgments, which can cause savings totals to vary between reporting periods. This indicates that while audit and investigative efforts continue to be critical, the final savings figures are often heavily dependent on legal and procedural timelines.

3. Future Oversight and Leadership Changes at HHS OIG: Looking ahead, the OIG plans to initiate reviews of how states are enforcing new Medicaid eligibility requirements, specifically verifying that enrollees are U.S. citizens or hold acceptable immigration status. Additionally, the recent confirmation of Thomas March Bell as the new inspector general introduces potential changes in the office’s direction, as he has expressed strong support for former President Trump. While Bell stated his intention to combat fraud and ensure HHS programs align with congressional goals, critics have voiced concern over whether he will uphold the independence and impartiality traditionally expected of the role.

Missouri sues drugmakers, PBMs over insulin pricing

By Ella Jeffries – The Missouri attorney general’s office has filed a lawsuit against 19 pharmacy benefit managers and drug manufacturers, alleging they conspired to inflate insulin prices and deceive consumers. The lawsuit claims the defendants engaged in deceptive and unfair practices that caused life-sustaining insulin prices to soar in the state, according to court documents. Read Full Article...

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1. Missouri Files Lawsuit Alleging Inflated Insulin Prices by Drugmakers and PBMs: The state of Missouri has filed a lawsuit in St. Louis County Circuit Court under the Missouri Merchandising Practices Act, accusing major insulin manufacturers—Eli Lilly, Novo Nordisk, and Sanofi—along with pharmacy benefit managers (PBMs) like CVS Health, Express Scripts, and OptumRx, of artificially inflating insulin prices. The suit claims that while insulin is sold for $300–$400 per vial in Missouri, it is available for under $5 abroad. Missouri aims to declare this pricing scheme unlawful, halt the conduct, and recover restitution for impacted consumers, particularly given that nearly 450,000 residents are uninsured and 18% of them are diabetic.

2. Defendants Push Back, Citing Price Reductions and Legal Compliance: The companies named in the lawsuit offered limited or firm responses. Eli Lilly labeled the lawsuit “wasteful,” asserting its leadership in improving insulin affordability through measures such as a 70% price reduction, a $35 monthly out-of-pocket cap, and a 2024 average monthly cost below $15. CVS and Sanofi did not comment specifically on the Missouri case but pointed to previous public statements; CVS reiterated that drug prices are set by manufacturers and called the suit “baseless,” while Sanofi claimed compliance with legal standards and blamed rebate structures for limiting patient savings.

3. Missouri Joins a Broader Nationwide Legal Challenge Over Insulin Pricing: This legal action places Missouri among a growing list of states—such as Delaware, Indiana, and Oregon—that are pursuing lawsuits targeting insulin pricing practices by many of the same companies. These cases reflect rising concern over affordability, with Delaware’s attorney general alleging insulin price hikes of up to 1,000% over 15 years, and Oregon seeking $900 million in damages. The Missouri lawsuit contributes to mounting pressure on both drugmakers and PBMs to justify their pricing strategies and the broader impact on public health and affordability.

How to turn health equity into cost advantage

By Jaqueline Oliveira-Cella – Early in my career as a young actuary in Brazil, I was often the only woman at the table. It didn't faze me. I was driven, trusted my technical skills and believed the world was limitless. Twenty years later, after pivoting to consulting and leading benefits for more than 350,000 employees across 100 countries, I learned a truth no spreadsheet could hide: awareness is priceless — and inequity is expensive — for people, performance and business outcomes. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Health Equity Is a Strategic and Economic Necessity: Racial and ethnic health disparities cost the U.S. hundreds of billions of dollars annually, while untreated depression and anxiety drain $1 trillion globally in lost productivity. Many families are now sacrificing essentials like food and care due to rising living costs. These inequities drive medical inflation and workforce strain, making health equity not just an ethical imperative but a core strategy for sustainable benefits and cost control.

2. Employers Can Drive Meaningful Change Through Inclusive Benefits: Employers can play a central role by redesigning benefits around inclusion. A “Benefits Bill of Rights” can help establish expectations for affordability, access, and dignity. Auditing exclusionary policies—like repeated prior authorizations for chronic conditions—can remove barriers to care. For example, over 90% of physicians report prior authorizations delay care, with 1 in 4 citing serious adverse outcomes. Working with brokers, vendors, and pooling networks enables organizations to close coverage gaps in key areas such as mental health and reproductive care.

3. Lasting Progress Requires Ongoing Metrics and Collaboration: Effective equity efforts rely on continuous feedback, including tracking access friction, delays, and employee trust. Many employees with chronic conditions don’t disclose them due to lack of safety, not secrecy. Inclusive technology and simplified navigation can help. Globally, employers can push for better coverage through collective action and shared standards. Equity-focused metrics — like time to care and absenteeism — should be tied to vendor accountability and reinvestment to sustain improvement over time.