As Trump Cuts Health, More May Exit Obamacare Like CVS Health’s Aetna

By Bruce Japsen - News that CVS Health’s Aetna is pulling out of the individual health insurance business, also known as Obamacare, could mean more insurers will follow if President Trump and his fellow Republicans in Congress cut health benefits. CVS’ decision, announced last week, leaves about 1 million people in 17 states looking for new coverage in 2026. That’s a fraction of the more than 24 million Americans who signed up for such coverage on the Affordable Care Act (ACA) exchanges last fall. Read Full Article…

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1. Republican efforts and subsidy expiration threaten ACA enrollment: The Trump administration and congressional Republicans are actively taking steps that could undermine the Affordable Care Act (ACA), including sharply cutting funding for navigators who assist consumers in signing up for coverage. With enhanced subsidies set to expire at the end of the year, and no clear commitment from Republicans to extend them, millions of Americans could face higher costs or lose access to affordable insurance if Congress doesn’t act.

2. Insurers face uncertainty despite recent growth in ACA markets: Major health insurers such as Centene, Oscar Health, UnitedHealthcare, and various Blue Cross and Blue Shield operators have seen record growth in ACA individual markets in recent years, largely thanks to expanded subsidies under the Biden administration. However, analysts caution that this momentum may slow or reverse if subsidies end, leading insurers to reassess participation and potentially scale back their coverage areas to minimize financial risks.

3. Potential market contraction could raise premiums and reduce coverage access: Industry experts warn that the possible expiration of enhanced subsidies could price millions of people out of ACA marketplace plans, creating affordability challenges for low- and middle-income enrollees. This financial pressure may prompt insurers to withdraw from certain counties or states, reducing consumer choice, shrinking provider networks, and driving up premiums for those who remain in the market.

House bill could eliminate ACA employer health coverage mandate

By Allison Bell - A new House bill could eliminate the Affordable Care Act employer health coverage mandate and also make many other changes in federal health insurance rules. Rep. Pete Sessions, R-Texas, introduced a new version of the Health Care Fairness for All Act bill Tuesday. The new bill is identical to a bill Sessions introduced in May 2023. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Preserves popular ACA protections with added penalties to encourage continuous coverage: The proposed bill retains key Affordable Care Act provisions, such as the ban on medical underwriting that prevents insurers from denying coverage based on preexisting conditions. However, it introduces a 20% late-enrollment penalty for individuals who sign up without prior coverage for at least 12 months, aiming to discourage people from waiting until they become ill to purchase insurance and promoting continuous enrollment in health plans.

2. Expands state flexibility and introduces Roth HSAs for broader coverage options: The bill promotes greater state-level innovation by supporting the creation of association health plans and high-risk pools to help cover individuals with significant health risks. It also proposes replacing current tax-deductible Health Savings Accounts (HSAs) with "Roth HSAs," which would allow consumers to contribute after-tax income in exchange for the ability to pair the account with lower-deductible, more flexible health insurance plans—potentially broadening access to more affordable coverage.

3. Increased likelihood of passage under Republican leadership amid uncertain Trump administration stance: With Republicans holding control of the House, Senate, and White House, the bill—which had stalled in committee during earlier efforts—now faces improved prospects for advancement. However, despite President Trump’s past statements favoring the repeal or replacement of ACA insurance rules, it remains unclear how actively his administration would support incremental changes like those proposed in this bill, as many ACA coverage provisions are expected to remain in place for the foreseeable future.

DOJ sues major insurers, brokers over alleged Medicare Advantage kickbacks

By Jakob Emerson - The Department of Justice has filed a sweeping lawsuit against Humana, Aetna, and Anthem, along with Medicare Advantage brokers eHealth, GoHealth, and SelectQuote, alleging a multi-year scheme involving unlawful kickbacks and discriminatory practices against disabled MA enrollees. Read Full Article… 

HVBA Article Summary

1. Insurers allegedly paid illegal kickbacks to brokers to steer Medicare Advantage enrollments: According to the DOJ lawsuit, Humana, Aetna, and Anthem paid hundreds of millions of dollars from 2016 through at least 2021 to major brokers like eHealth and GoHealth in the form of disguised “marketing” fees, bonuses, and other incentives. These payments allegedly secured preferential treatment, leading brokers to steer Medicare beneficiaries toward the insurers’ Medicare Advantage plans—often prioritizing commissions over plan quality or beneficiary needs, and sidelining competing plans that didn’t pay similar incentives.

2. Brokers and insurers allegedly conspired to discriminate and manipulate enrollment outcomes: The complaint further alleges that Humana and Aetna collaborated with brokers to deliberately screen out or discourage enrollment by disabled individuals, who are typically more costly to insure. This was reportedly achieved through data filtering, call-routing tactics, and other methods designed to reduce disabled beneficiaries in their plans—an approach the DOJ argues violated federal anti-discrimination laws and unfairly limited access to coverage for vulnerable populations.

3. DOJ seeks significant penalties for false claims, kickbacks, and anti-discrimination violations: The federal government claims that these unlawful insurer-broker arrangements resulted in the submission of thousands of false claims to CMS, breaching the Anti-Kickback Statute, the False Claims Act, and anti-discrimination provisions in Medicare Advantage contracts. The DOJ is seeking triple damages, civil penalties for each false claim, and other remedies. Meanwhile, Humana, Aetna, Anthem, and the brokers deny wrongdoing, assert compliance with CMS rules, and plan to vigorously defend themselves against the allegations.

3 Ways Companies Can Make Healthcare More Affordable

By Marcy Tatsch - Businesses are struggling with the high cost of healthcare benefits for their employees. As companies prioritize their employees’ well-being, healthcare benefits are often their largest expense, second only to the cost of goods and services they provide. Costs of employer-sponsored healthcare are expected to rise 9% in 2025. Read Full Article… 

HVBA Article Summary

1. Measure and manage GLP-1 outcomes with integrated data: Employers should track the financial and clinical impact of GLP-1 drugs by combining pharmacy, medical, biometric, lab, and productivity data. This enables them to monitor utilization, evaluate return on investment from both health and productivity perspectives, and guide long-term prescription strategies for diabetes and weight management.

2. Use data to improve mental health access and accountability: By leveraging socio-demographic and population health data, employers can better identify needs, reduce care barriers, and tailor mental health programs for diverse employee groups. Linking vendor and internal data also helps companies hold vendors accountable for outcomes and ensure services effectively reach those most in need.

3. Leverage pricing data to negotiate better healthcare contracts: Employers should use Medicare repricing, Transparency in Coverage files, paid claims data, and analytics to identify cost drivers, benchmark prices, and negotiate more favorable rates. This data-driven approach supports more sustainable healthcare costs while maintaining quality and affordability for employees.

How AI is simplifying healthcare claims

By Paola Peralta - The way people are billed for their healthcare needs determines their whole experience, and as it stands, patients and providers alike are largely dissatisfied. AI has the power to change that. Sixty-four percent of healthcare professionals say insurance claim denials are their top billing challenge, according to a recent study from healthcare software developer Tebra, and 54% site delays as the runner up. As a result, 54% of healthcare pros plan to adopt AI billing systems in the next one to two years, with 30% saying they've already done so. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. AI is streamlining healthcare operations by reducing administrative burdens and improving billing accuracy: Healthcare providers face inefficiencies from payer requirements, coding errors, and claim denials, with nearly 1 in 5 providers spending over 20 hours monthly fixing billing mistakes. AI can flag errors in real time, analyze denial trends, and automate repetitive tasks, leading to faster reimbursements and freeing up time for patient care.

2. Patients also benefit from AI-driven billing improvements, helping reduce financial stress and confusion: With 45% of patients receiving unexpected medical bills and 44% delaying essential purchases as a result, AI tools like chatbots can answer patient billing questions, while automated systems help prevent surprise charges by catching errors before claims are denied.

3. A thoughtful, phased approach to AI implementation is critical for success in healthcare settings: Experts emphasize the need to map existing pain points, choose AI tools that integrate with electronic health records, and adopt training and compliance measures to ensure accuracy, oversight, and smooth adoption in this highly regulated industry.

CVS Health to exit Obamacare; in pact with Novo to improve Wegovy access

By MSN - CVS Health (NYSE:CVS) on Thursday announced plans to discontinue operations in the individual health insurance business, also known as Obamacare, next year. The company made the announcement with its Q1 2025 financials, which exceeded street forecasts and sent its shares ~7% higher in the premarket. Read Full Article…

HVBA Article Summary

1. CVS Caremark partners with Novo Nordisk to prefer Wegovy: CVS announced that starting July 1, its pharmacy benefit manager, CVS Caremark, will give formulary preference to Novo Nordisk’s weight loss drug Wegovy over Eli Lilly’s Zepbound, aiming to improve access and affordability for its members.

2. CVS exits ACA individual market amid financial challenges: CVS confirmed it will exit the ACA individual exchange market for 2026 after Aetna, its insurance unit, recorded a $448 million premium deficiency reserve, despite Aetna’s 8% year-over-year revenue growth and improved Medicare Advantage performance.

3. Strong financial results drive raised guidance: CVS reported $94.6 billion in quarterly revenue—exceeding forecasts—and a 72% increase in adjusted EPS to $2.25, prompting the company to raise its full-year earnings guidance to $6.00–$6.20 per share, citing solid growth across all business segments.

Benefits Think: Leveraging population health to build a healthy workforce

By Andrew Cass - Rising healthcare costs, combined with the increasing prevalence of chronic illnesses and mental health challenges, are placing significant financial and operational strain on employers. However, many organizations still rely on fragmented solutions that struggle to address the root causes of these challenges. The real opportunity lies in adopting a strategic, population health approach with clinical guidance — one that moves beyond temporary fixes to deliver meaningful and lasting change. Read Full Article… ^{_{(Subscription required)}} 

HVBA Article Summary

1. Clinical expertise enhances strategic benefit design and health outcomes: By collaborating with chief medical officers (CMOs) and clinical experts, employers can integrate evidence-based strategies, address underlying drivers of poor health, and foster a culture of well-being—moving beyond cost containment to improve both employee health and organizational performance.

2. Benefit brokers play a key role by aligning clinical guidance with employer goals: Brokers and advisers can strengthen their value by partnering with clinical leaders to design holistic health programs that meet employees’ physical, mental, and emotional needs across the population health continuum, boosting productivity, morale, and financial outcomes.

3. Data-driven strategies enable continuous improvement and responsive care: Employers can leverage claims data and workforce health analytics to monitor outcomes, implement targeted interventions, and refine benefit plans—ensuring programs remain effective, adaptable, and supportive of long-term health and cost goals.