Is This The Beginning of The End for Big Insurance?

By Wendell Potter – This week we are seeing what a tragic mistake we as a country made in turning our health care system over to corporations like UnitedHealth Group that live and die on Wall Street. And it’s only Wednesday. I hope lawmakers are paying attention because we very well could be heading into an ongoing collapse of the health insurance industry’s market capitalization and the ability of insurance giants to keep the lights on without a taxpayer bailout. I am not crying wolf. Access to care for hundreds of millions of Americans is at stake. Read Full Article...

HVBA Article Summary

1. Significant Market Decline for Big Insurance: UnitedHealth Group's disappointing 2025 earnings and bleak 2026 revenue outlook caused its stock price to drop 20%, triggering a sector-wide decline that erased up to $100 billion in market capitalization across seven major insurers. This sharp fall reflects waning investor confidence and signals potential financial instability within the health insurance industry, which could impact their operational capabilities without government intervention.

2. Regulatory Pressure and Industry Challenges: The Trump administration's Center for Medicare & Medicaid Services (CMS) surprised the industry by proposing a minimal 0.09% increase in Medicare Advantage payments for 2027 and committing to crack down on insurer overbilling. This unexpected regulatory stance, coupled with ongoing investigations into UnitedHealth's Medicare Advantage business, indicates increasing scrutiny and efforts to reduce waste, fraud, and abuse, challenging insurers' profitability and business models.

3. Potential Impact on Access to Care and Insurance Offerings: As insurers face financial pressures and regulatory constraints, they are expected to increase premiums, reduce coverage options, and tighten provider networks. Major companies like UnitedHealth and Aetna are withdrawing from unprofitable markets, shrinking Medicare Advantage enrollment, and likely increasing claims denials and restrictions. These changes threaten to make health coverage less affordable and accessible for millions of Americans, highlighting the urgent need for legislative action to address the evolving crisis.

Congress is poised to bring big changes to PBMs

By Peter Sullivan – Congress may be about to make long-sought changes to pharmacy benefit managers' business practices — though the impact on drug costs could be limited. Why it matters: PBMs negotiate drug prices with drug manufacturers on behalf of health plans and the prospect of changing how they're compensated could remove what critics say are warped incentives that can encourage the use of higher-priced drugs. Read Full Article...

HVBA Article Summary

1. Legislative Changes Target PBM Compensation Structure: The proposed bipartisan health care deal aims to change how pharmacy benefit managers (PBMs) are paid in Medicare Part D by moving from compensation tied to drug prices to a flat fee model. This shift is intended to address concerns that current incentives may encourage PBMs to favor higher-priced drugs. If enacted, the new structure could potentially lower patients' coinsurance payments, which are currently based on drug prices.

2. Transparency and Oversight Provisions Included: The legislation also introduces new transparency and reporting requirements for PBMs, which supporters argue will help health plans negotiate better deals and shed light on opaque business practices. Experts note that PBMs have historically operated with limited visibility into their financial arrangements, making it difficult for stakeholders to assess their impact on drug costs. Increased transparency is seen as a critical step toward holding PBMs accountable within the broader health care system.

3. Uncertainty Remains Over Legislative Passage and Impact: While the House has passed the package, its fate in the Senate is uncertain due to its attachment to broader government funding measures. There is bipartisan support for the health provisions, but disagreements over other aspects of the funding package could delay or alter its passage. Even if the reforms are enacted, experts caution that PBMs' evolving business models and use of subsidiaries may complicate efforts to fully address cost and accountability issues.

UnitedHealthcare expects to lose up to 2.8 million members in 2026 - Becker's Payer Issues

By Jakob Emerson – UnitedHealth Group reported its fourth quarter and full year 2025 earnings Jan. 27, projecting membership declines between 2.3 million and 2.8 million across its Medicare Advantage, Medicaid and commercial business lines in 2026 as the company prioritizes margin recovery following a turbulent financial year. UnitedHealthcare’s total earnings from operations were $9.4 billion in 2025, down about 40% year-over-year from $15.6 billion in 2024. The insurer’s operating margin dipped to 2.7% in 2025, compared to 5.2% in the previous year. The company projects $10.8 billion in operating earnings and a 3.2% operating margin in 2026. Read Full Article...

HVBA Article Summary

1. Significant Membership Declines Expected: UnitedHealthcare is forecasting a substantial reduction in membership across its Medicare Advantage, Medicaid, and commercial business lines for 2026. The projected losses are attributed to a combination of competitive pressures, state funding challenges, and strategic pullbacks in underperforming markets. These declines reflect the company's shift in focus toward improving profitability and operational margins after a financially challenging year.

2. Strategic Shifts in Business Segments: The company is making notable changes in its approach to various segments, including scaling back its presence in the ACA exchange market and narrowing its Optum Health provider network. UnitedHealthcare is also reducing risk-based contracts and exiting markets where financial terms are not favorable. These moves are intended to stabilize earnings and return to the core intent of value-based care, while also responding to regulatory and market pressures.

3. Increased Investment in Technology and AI: UnitedHealth plans to invest nearly $1.5 billion in artificial intelligence and related technologies in 2026, with a similar investment expected the following year. The company has already implemented over 1,000 AI use cases and employs more than 2,000 AI engineers, aiming to enhance operational efficiency and regain customers lost after previous disruptions. This focus on technology is seen as a key driver for future growth and margin improvement.

The 'voluntary' benefits wake-up call: ERISA is watching

By Eric Silverman – For years, voluntary benefits lived in a comfortable gray area. Employees paid the premiums. Employers offered access. Direct-to-market carrier reps, enrollment firms, and/or brokers facilitated enrollment. And the prevailing belief was simple – if it is voluntary, the risk is minimal. That belief is now being tested. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Fiduciary Responsibility in Enhanced Benefits Is About Process, Not Product: The recent wave of ERISA lawsuits is not questioning the value of Enhanced Benefits themselves—such as accident or critical illness plans—but rather the lack of proper governance in how these benefits are handled. Employers and advisors must go beyond offering options and demonstrate a careful, well-documented process in selecting carriers, pricing premiums, monitoring plan performance, and disclosing broker compensation. In today’s regulatory climate, simply stating that participation is voluntary is no longer a valid defense against fiduciary liability.

2. Compensation Models and Enrollment Methods Must Align with Fiduciary Standards: A significant concern highlighted in litigation involves how commissions and fees are structured and disclosed. The issue isn’t compensation itself, but the alignment of incentives with the employer's fiduciary duties. Traditional models that reward upfront enrollment volume without long-term oversight may pose risks if not transparently managed. Similarly, self-service enrollment platforms are not problematic on their own, but they must be backed by clear decision support, education tools, and oversight. The method of enrollment doesn’t remove the need for fiduciary care upstream.

3. Decision Support Is the Industry’s Needed Evolution: The key shift the industry must embrace is moving from passive benefit offerings to active support that helps employees make informed decisions. That includes clear educational content, technology that simplifies rather than overwhelms, and AI-driven tools that highlight relevant coverage gaps. Most importantly, documentation of how these supports are implemented is critical. Lawsuits are signaling that fiduciaries must not only offer benefits but also prove they supported employee decisions responsibly and transparently. This evolution enhances outcomes without reducing choice.

Interconnectedness, extortion risk make cybersecurity a healthcare C-suite priority

By Eric Geller – Rapid digitization and increasing interconnectedness in the healthcare industry are “exposing clinical technology to threats it was never engineered to withstand,” Trellix said in a report published on Tuesday. The threat intelligence report, based on 54.7 million detections from Trellix products in healthcare environments in 2025, highlighted email as the top threat vector (85% of all detections) and the U.S. as the biggest target (75% of all detections). Trellix’s report also described the evolution of the ransomware ecosystem. The “cascading effect,” in which a disruption of one system causes a chain reaction that paralyzes other systems, represented “the defining trend of 2025” in healthcare cybersecurity, according to Trellix. Read Full Article...

HVBA Article Summary

1. Healthcare Cybersecurity Risks Are Increasing Due to Digitization: The healthcare sector's rapid adoption of digital technologies and interconnected systems has exposed clinical technologies to new and unprecedented cybersecurity threats. This expanded attack surface includes cloud adoption, remote access, and AI-driven workflows, which have made cyber incidents a critical patient safety issue rather than just an IT problem. The report emphasizes that disruptions caused by cyberattacks can have lethal consequences, affecting patient care and mortality rates.

2. Ransomware Threats Are Evolving and Targeting Healthcare Specifically: Multiple ransomware groups have intensified their focus on healthcare organizations in 2025, using sophisticated malware targeting electronic health records and other critical systems. Groups like Qilin, INC Ransom, Sinobi, and Devman2 have been particularly active, with some attacks involving massive data exfiltration. The rise of extortion-only tactics, which increased by 300% since 2023, reflects attackers exploiting healthcare's sensitivity to private data and bypassing traditional corporate defenses by demanding smaller, per-patient ransoms.

3. Phishing Remains the Primary Breach Vector with Increasing Sophistication: Phishing attacks account for 89% of initial access incidents in healthcare cybersecurity breaches. Attackers are tailoring their phishing lures to appeal to IT administrators by using themes such as “AI Transformation” and “Regulatory Compliance.” Additionally, hackers employ malicious domains and subdomains with healthcare-related terms like “HIPAA” to establish command-and-control infrastructure, making detection and defense more challenging for healthcare organizations.

Telehealth boosts preventive care in rural areas

By Anuja Vaidya – Telehealth utilization in rural areas was associated with a higher likelihood of utilizing preventive care, recent research revealed. Published in the American Journal of Managed Care, the research assessed whether telehealth use among rural residents affected subsequent preventive care utilization. The study authors noted that rural residents are less likely to receive preventive health services. Prior research has shown that barriers to primary care access, including travel and transportation challenges, limit Americans' use of preventive care. Read Full Article...

HVBA Article Summary

1. Telehealth Increases Preventive Care Access: The study found that rural residents who used telehealth services were more likely to complete preventive care visits or services in subsequent years compared to those who did not use telehealth. This suggests that telehealth can help bridge gaps in healthcare access for rural populations, who often face challenges such as long travel distances and limited provider availability. By making it easier to connect with healthcare professionals, telehealth may encourage more consistent engagement with preventive health measures.

2. Demographic and Regional Differences Observed: The research highlighted that the positive association between telehealth use and preventive care was not uniform across all groups. Women and individuals living in the West and South regions showed a stronger link between telehealth use and preventive care uptake. Additionally, people with asthma benefited more from telehealth in terms of preventive care than those with diabetes or hypertension, indicating that the impact of telehealth may vary based on specific health conditions and demographics.

3. Policy Implications Amid Regulatory Changes: The findings come at a time when telehealth policy is in flux, with pandemic-era regulatory flexibilities set to expire unless extended by Congress. The House Appropriations Committee has proposed extending these flexibilities, which could have significant implications for rural healthcare access. The study's results may inform future policy decisions by demonstrating the value of telehealth in promoting preventive care, especially for underserved rural populations.

Demand for compliance support is rising, says over half of benefit advisors

By Alan Goforth – Compliance pressures, AI adoption and economic uncertainty are driving increased demand for broker services and reshaping brokers into trusted advisors across the HR function. "For 40 years, we've worked closely with the broker community as compliance, benefits and workforce needs have continually evolved, and 2026 is no exception," said Jura Slattery, chief customer officer at isolved. "What's different now is the pace of change. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Compliance Expertise is a Leading Broker Advantage: With 58% of brokerage professionals citing increased demand for compliance support, regulatory knowledge has become a key differentiator. Top client concerns for 2026 include ERISA (57%), COBRA (51%), and the Family Medical Leave Act (47%). Additionally, 47% of brokers expect rising healthcare costs and 46% anticipate stricter data privacy regulations to significantly impact their business in the next 2–3 years.

2. HR-Broker Relationships Are Expanding Beyond the Basics: A full 93% of brokers say clients now expect more than traditional services. AI guidance (46%) and compliance support (36%) top client requests, and newer offerings are gaining momentum. For instance, while only 21% of brokers currently offer commuter benefits, another 24% plan to do so within the next year—bringing the total to 45%. Brokers are becoming more integrated partners in addressing broader workforce needs.

3. AI Adoption is High, But the Human Element Still Counts: 85% of brokers are using or exploring AI, primarily for automated compliance monitoring (53%) and personalized financial wellness planning (50%). Reported benefits include streamlined compliance (64%), improved employee engagement (61%), and faster hiring (49%). However, 55% believe AI underdelivers on the human side of HR, emphasizing that trust, empathy, and connection remain essential components of broker value.