Big Insurance CEO Hearings: 5 Clips to Watch

By Wendell Potter and Joey Rettino – Last week, the U.S. House Energy and Commerce and Ways and Means Committees summoned five of the most powerful executives in the American health insurance industry to answer for their outsized roles in the U.S.-health ecosystem. And how their roles are leaving Americans increasingly sicker and poorer while they turn a profit. For starters, let’s take a moment to acknowledge that the hearing was unprecedented. Even in the days leading to the passage of the Affordable Care Act (ACA), we didn’t see a panel of Big Insurance CEOs being hauled before Congress like we saw last week. Until recently, these executives (and the companies they lead) have largely dodged Congressional scrutiny and accountability. Read Full Article...

HVBA Article Summary

1. Congressional Scrutiny of Health Insurance Giants: The recent hearings marked a significant shift in Congressional oversight, as top executives from major health insurance companies were called to testify about their influence on the U.S. health care system. This level of direct questioning and accountability had not been seen even during major legislative moments like the Affordable Care Act debates. The hearings reflect growing bipartisan concern over the power and practices of these companies.

2. Concerns Over Vertical Integration and Market Power: Lawmakers highlighted the extensive vertical integration of health insurers, who now control not just insurance but also medical providers, pharmacies, and pharmacy benefit managers. This consolidation raises questions about competition, pricing, and the ability of patients to access affordable care. Some representatives argued that such concentration allows these companies to set prices and policies across the entire health care chain, potentially to the detriment of consumers.

3. Political Influence and Public Trust Issues: The hearings also addressed the political activities of health insurers, including large donations to ballot measures and political committees. Lawmakers questioned whether such contributions undermine public trust and the impartiality of health policy decisions. The discussion underscored concerns that the financial and political clout of these companies may be used to shape legislation and regulation in their favor, rather than prioritizing patient needs.

More than 75 health systems call for stepped-up oversight of patient data sharing

By Heather Landi – More than 75 health systems sent a letter to federal officials calling for stronger oversight of nationwide data sharing networks, flagging issues with "bad actors" gaining access to patients' medical information. The health systems, including AdventHealth, Cedars-Sinai Medical Center, The MetroHealth System, NYU Langone, UMass Memorial Health, Stanford Health Care and Sutter Health, are calling for more centralized oversight and governance for the nationwide health data exchange frameworks, including the Trusted Exchange Framework and Common Agreement (TEFCA) and Carequality. Read Full Article...

HVBA Article Summary

1. Call for Centralized Oversight: The letter from over 75 health systems highlights concerns that current decentralized and self-attested processes for joining national health data exchanges are inadequate to protect patient privacy. The organizations advocate for a more centralized approach to vetting, onboarding, and monitoring participants in frameworks like TEFCA and Carequality. They believe this would help prevent unauthorized access and improve accountability across the networks.

2. Recommendations for Enhanced Security and Transparency: The health systems propose several measures to strengthen data sharing safeguards, including hiring dedicated staff to review prospective network participants, implementing automated fraud detection, and establishing public directories of data access. They also suggest that organizations should attest to their business purposes directly to federal agencies, making false claims prosecutable offenses. Increased transparency about who accesses data and for what reasons is seen as essential for building trust in these networks.

3. Industry Context and Legal Implications: The push for stronger oversight comes amid ongoing legal disputes, such as the lawsuit involving Epic and Health Gorilla, which centers on alleged improper access and monetization of patient records. Many of the letter's signatories are also involved in this litigation, underscoring the urgency of addressing data misuse. The recommendations include creating a digital health fraud task force and making dispute resolutions public to deter future violations and foster a culture of compliance.

West Virginia fines Navitus $800K over pharmacy reimbursement, rebate violations

By Allison Bell – West Virginia Insurance Commissioner Allan McVey has imposed an $800,000 penalty on Navitus, a pharmacy benefit manager, in connection with allegations that the PBM violated the state's pharmacy audit, pharmacy reimbursement and rebate pass-through rules, according to an order posted on the website of the West Virginia Offices of the Insurance Commissioner. PBMs help employer-sponsored health plans and other health coverage providers set up and run prescription drug benefits programs. West Virginia started licensing PBMs in 2020, and regulators there have frequently imposed fines on PBMs found to be in violation of the state PBM rules. Navitus declined to comment on the West Virginia order. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Regulatory Action and Violations: West Virginia fined Navitus $800,000 after finding violations related to pharmacy audits, reimbursement practices, and rebate pass-through requirements. The state has been actively enforcing its PBM regulations since licensing began in 2020, with Navitus being one of several PBMs penalized. These actions reflect a broader trend of increased scrutiny on PBM operations at the state level.

2. Rebate and Reimbursement Practices: Regulators discovered that Navitus entered into an agreement with Prime Therapeutics, resulting in a PBM retaining about $540,000 in negotiated rebates rather than passing them fully to consumers. Additionally, Navitus sometimes reimbursed West Virginia pharmacies at rates below the national average drug acquisition cost plus the required dispensing fee. In certain cases, affiliated pharmacies received significantly higher payments than non-affiliated ones, raising concerns about competitive fairness.

3. Broader Implications for PBM Transparency: The enforcement in West Virginia comes as other states and Congress consider or implement PBM transparency laws. Supporters argue that such regulations could lower drug prices and benefit both employers and consumers, while PBMs warn that increased oversight may limit their ability to negotiate savings and could lead to higher costs. The outcome of these enforcement actions may influence how similar regulations are applied and enforced nationwide.

A bad week for health insurers

By Jakob Emerson – Over the past week, health insurers have drawn the ire of lawmakers on both sides of the aisle and seen their collective stock prices drop by nearly $100 billion following unfavorable Medicare Advantage news from CMS. All this while millions of Americans face rising marketplace premiums after the expiration of enhanced ACA subsidies, and employers face sticker shock as the average cost to offer health benefits has risen by as much as 10%. Read Full Article...

HVBA Article Summary

1. Congressional Hearings and Vertical Integration Concerns: Lawmakers held a nine-hour hearing on January 22 with the CEOs of UnitedHealth, CVS Health, Cigna, Elevance, and Ascendiun, focusing on claims denials, prior authorizations, and executive compensation. A central concern was the growing vertical integration of health conglomerates—insurers owning pharmacies, physician practices, and pharmacy benefit managers (PBMs). Lawmakers from both parties expressed alarm over the potential impact on patient access and care quality, with some calling for nonprofit reforms or stronger oversight of for-profit healthcare models.

2. Medicare Advantage Rate Proposal and Market Reaction: On January 26, CMS proposed a 0.09% increase in Medicare Advantage (MA) payments for 2027—far below analyst expectations. The agency also introduced changes to MA risk adjustment calculations, such as excluding unlinked chart review diagnoses, potentially cutting into insurer margins. The announcement triggered a selloff among major insurers, wiping out nearly $100 billion in market value. UnitedHealth forecast its first revenue decline in decades and anticipates losing up to 1.4 million MA members in 2026. Industry groups warned the proposed changes could result in reduced benefits and higher enrollee costs if finalized.

3. Healthcare Cost Pressures and Coverage Reductions: Insurers across ACA, Medicaid, and employer-sponsored markets are facing rising costs and shrinking coverage. In the ACA marketplace, the expiration of enhanced subsidies is expected to raise average premiums by 114%, from $888 in 2025 to $1,904 in 2026. UnitedHealth projects exchange margins around 1%. In Medicaid, eligibility tightening and funding shortfalls could result in enrollment losses of 565,000 to 715,000 in 2026, and up to 10 million over the next decade. Employer health benefit costs are projected to rise nearly 10% nationally, with commercial group medical costs climbing almost 9% in 2026 due to chronic conditions, drug spending, and higher utilization.

Medicare selects GLP-1, Botox for negotiations

By Maya Goldman – Medicare wants to negotiate lower prices for Eli Lilly's GLP-1drug Trulicity and AbbVie's Botox in its next round of drugmaker negotiations, federal health officials announced Tuesday. The GOP budget law passed over the summer excluded several high-cost drugs from being selected for negotiations. Still, the 15 drugs chosen accounted for $27 billion of Medicare spending between November 2024 and October 2025, per the Centers for Medicare and Medicaid Services. The negotiated prices would take effect in 2028. Read Full Article...

HVBA Article Summary

1. Expansion of Medicare Price Negotiations: For the first time, Medicare is including prescription drugs administered in doctors' offices and outpatient settings in its price negotiation process. This marks a significant expansion of the program, which previously focused on medications dispensed at pharmacies. The move is expected to impact both patients and drug manufacturers by potentially lowering costs for widely used treatments.

2. Drugmakers Face Participation Decisions and Penalties: Pharmaceutical companies whose drugs are selected for negotiation must decide by February 28 whether to participate. If they opt out, they face substantial penalties, including an excise tax of up to 95% of U.S. sales or withdrawal of their drugs from Medicare and Medicaid coverage. This creates strong incentives for manufacturers to engage in the negotiation process despite ongoing legal challenges.

3. Political and Legal Context Surrounding Negotiations: The selection of drugs for negotiation is guided by statutory criteria, limiting the administration's discretion in the process. While President Trump has made separate deals with some drugmakers to lower prices, these companies are still subject to Medicare negotiations. Multiple lawsuits have been filed by pharmaceutical companies to halt the program, but none have succeeded, and the Supreme Court has been asked to review the issue.

Obesity to rise by 19 million and affect 126 million American adults by 2035, new study finds

By Dr. Camille Charles – The number of Americans living with obesity is expected to rise by 19 million and affect nearly 126 million people by 2035, according to a new study published in the Journal of the American Medical Association on Wednesday. Researchers found that the number of American adults living with obesity has more than doubled over the past 30 years, increasing from 34.7 million in 1990 to an estimated 107 million American adults in 2022. New findings suggest that this upward trend is expected to continue. “Our projections indicate that almost half of US adults will be living with obesity by 2035,” Dr. Catherine O. Johnson, lead research scientist at the Institute for Health Metrics and Evaluation at the University of Washington and co-author of the study, told ABC News. Read Full Article...

HVBA Article Summary

1. Projected Increase in Obesity Prevalence: The study forecasts that by 2035, nearly 126 million American adults will be living with obesity, marking an increase of 19 million from current numbers. This projection indicates that almost half of the adult population in the U.S. will be affected, continuing a trend of significant growth in obesity rates over the past three decades.

2. Demographic and Regional Disparities: The research highlights that women are more affected by obesity than men, with Southern states showing higher obesity rates. Adults aged 45 to 64 have the highest prevalence, while younger women under 35 are experiencing the fastest increase. Additionally, Black women have the highest obesity rates, followed by Hispanic women, suggesting that socioeconomic factors such as income, healthcare access, and environment contribute to these disparities.

3. Health and Economic Implications: Obesity is linked to numerous health issues including diabetes and cardiovascular disease, especially with earlier onset in younger populations. The rising obesity rates are expected to increase healthcare costs, which were estimated at nearly $200 billion in 2019. The study emphasizes the urgent need for effective public health strategies and equitable clinical interventions to address this growing public health threat.

Biologic Plus GLP-1 Agonist Improves Quality of Life in Psoriatic Disease

By Ted Bosworth – When obesity and psoriatic diseases were treated concomitantly with a biologic and a GLP-1 receptor agonist (RA), more than 90% of patients reported satisfaction with their treatment, in a newly completed real-world study. The high rate of patient satisfaction was based on a cross-sectional survey, not a placebo-controlled assessment, so drug interactions for quality of life measures could not be measured, but patient satisfaction was high, according to a collaborating group of dermatologists and rheumatologists that included April Armstrong, MD, professor and chief of dermatology at the University of California, Los Angeles. Read Full Article...

HVBA Article Summary

1. Combined Treatment Shows High Patient Satisfaction: The study found that patients with both psoriatic disease and obesity who were treated with a biologic (ixekizumab) and a GLP-1 receptor agonist (tirzepatide) reported high levels of satisfaction. This satisfaction was attributed to good control of both psoriatic symptoms and weight management. The results suggest that addressing both conditions simultaneously may improve overall quality of life for these patients.

2. Real-World Evidence and Study Limitations: The findings are based on a cross-sectional survey of 174 patients enrolled in a manufacturer support program, rather than a randomized controlled trial. While the survey indicates positive outcomes, it does not establish causality or directly compare the effectiveness of combined therapy versus monotherapy. The authors acknowledge that further clinical validation is needed to confirm these results.

3. Guideline Support and Underlying Mechanisms: Current guidelines from dermatology and rheumatology organizations recommend treating obesity and psoriatic disease together when they coexist, due to shared inflammatory pathways. The study reinforces the link between obesity and increased severity of psoriatic disease, as well as the potential for weight loss to improve disease outcomes. These findings highlight the importance of a comprehensive approach to managing patients with both conditions.