Trump pushes 'cash-for-coverage' accounts for health insurance

By Allison Bell – President Donald Trump is continuing to signal that he is interested in providing cash that people can use to buy their own health coverage, rather than sending subsidy money to health insurers through the current Affordable Care Act premium subsidy tax credit system. Trump talked about the federal cash-for-coverage idea Monday on a Fox News talk show hosted by Laura Ingraham. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Trump Supports Direct Consumer Control Over Health Subsidies: In a recent interview and Truth Social post, Donald Trump endorsed a health care policy shift where federal insurance subsidies would be directed into individual consumer accounts. This approach would allow people to purchase their own insurance, bypassing insurance companies, which he characterized as "money sucking." He believes this model would result in lower costs and better insurance options for consumers. This reflects a broader push by some conservatives to reduce government involvement in the insurance market and empower individual choice.

2. Republican Views on ACA Subsidies Are Divided: While some Republicans support a complete overhaul of the current ACA subsidy system in favor of cash accounts (similar to health savings accounts), others advocate for extending enhanced subsidies introduced during the COVID-19 pandemic. The latter group wants to ensure continuity in coverage, especially for individuals with pre-existing conditions, until a new system is finalized. This split indicates ongoing tension within the party between reform-minded factions and those favoring a more cautious transition.

3. Potential Impact on Insurance Markets and Employer Coverage: Analysts warn that poorly executed changes to ACA subsidy structures could destabilize insurance markets by driving high-cost individuals to specific insurers, overwhelming them with claims. A return to pre-ACA rules, if part of Trump's approach, might raise employer claim costs due to more uninsured individuals but could also reduce employer obligations by lifting some coverage mandates. These changes could lead to both higher risk and greater flexibility in how employers structure health benefits.

Why AI must be clinically trained to transform the prior authorization process

By Gigi Yuen – Beginning in January 2026, sweeping changes to prior authorization will take effect. Federal mandates will require health plans to digitize the exchange of clinical documentation, meet new turnaround times–seven days for standard requests, 72 hours for urgent–and maintain performance transparency through new reporting standards. These mandates, along with recent public commitments from AHIP, HHS, and health plans nationwide, are long overdue. Read Full Article... ^{_{(Subscription required)}}

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1. Generic AI and legacy systems fail to address clinical complexity: Automation alone cannot solve the long-standing challenges in prior authorization, such as inconsistent guidelines, administrative delays, and opaque decision-making. Generic AI tools—often trained on limited or non-clinical data—lack the ability to understand nuanced medical scenarios. As a result, these tools risk replicating inefficient processes instead of improving them, especially when they overlook individualized patient needs.

2. Clinician-trained, purpose-built AI offers better alignment with patient care: AI models developed in partnership with clinicians are specifically designed to reflect real-world medical practice. These systems analyze unstructured clinical data, adapt to changing care standards, and evaluate requests with the same reasoning a physician would use. By embedding clinical intelligence into workflows and maintaining physician oversight, they enhance decision-making while preserving the human touch essential to quality care.

3. Responsible AI supports transparency, regulation, and physician trust: Clinical-grade AI promotes accountability by enabling each decision to be explained, audited, and traced back to a clinician. With continuous input from medical professionals and adherence to evolving best practices, these systems ensure decisions remain evidence-based and patient-centered. This not only supports compliance with upcoming regulations but also fosters stronger payer-provider relationships built on transparency and shared clinical standards.

Shutdown has highlighted Washington’s retreat from big ideas on healthcare

By Stephanie Armour – In the run-up to the 2020 election, all 20 Democratic presidential candidates promised voters they’d pursue bold changes to health care, such as a government-run insurance plan or expanding Medicare to cover every American. Fast-forward to the congressional stalemate that has closed the federal government for more than a month. Democrats, entrenched on one side of the legislative battle, staked their political future on merely preserving parts of the Affordable Care Act—a far cry from the systemic health policy changes that party members once described as crucial for tackling the high price of care. Read Full Article...

HVBA Article Summary

1. Democrats are focused on protecting ACA subsidies, but lack bold reforms: Democrats have centered their health care strategy on extending enhanced ACA tax subsidies, which have helped lower premiums for approximately 24 million Americans. If not renewed, premiums could more than double for many enrollees. While this defensive stance may protect them politically in the short term, critics — including Jon Stewart and Democratic officials — argue the party is failing to address voters’ growing demand for structural reform like universal health care and price regulation.

2. Health care affordability is a top concern for voters amid rising costs: Health care costs now outpace inflation and wage growth, with premiums for job-based family coverage averaging $26,993 in 2025 — a 6% increase from the previous year. Meanwhile, 4 in 10 adults carry some form of medical debt, and 6 in 10 Americans are extremely or very worried about rising health care costs in the coming year. In polls, voters rank health care affordability as a higher priority than housing, jobs, crime, or immigration, highlighting the public’s intense financial strain and policy expectations.

3. Systemic reform is stalled by political division, despite bipartisan interest: Sweeping federal reforms are unlikely in the current political landscape, as Democrats lack control of Congress and remain cautious after previous political setbacks like the ACA backlash. While bipartisan bills to improve price transparency and regulate pharmacy benefit managers briefly gained traction in 2024, they were ultimately dropped after public criticism from Elon Musk, influencing GOP leaders to remove health provisions from a budget bill. In contrast, some states — notably Oregon — are pushing ahead with single-payer models, aiming to eliminate premiums and deductibles entirely by 2027.

Shutdown deal extends Medicare telehealth coverage

By Maya Goldman – The Senate deal to reopen the government would extend Medicare telehealth coverage through Jan. 30 and pay retroactively for virtual care services delivered during the government shutdown. Why it matters: If passed by Congress, the government funding deal would provide relief for seniors and providers who've come to rely on Medicare paying for virtual visits since the COVID-19 pandemic. Read Full Article...

HVBA Article Summary

1. Medicare Telehealth Expiration: Medicare's temporary authority to reimburse virtual care provided outside of rural settings expired on October 1. As a result, many healthcare providers were forced to cancel telehealth appointments or risk not getting paid. Although there is strong bipartisan support in Congress to make this coverage permanent, progress has been stalled due to concerns over the potentially high cost — estimated in the billions of dollars.

2. Short-Term Health Policy Extensions: A new Senate agreement retroactively extends several key health policies from October 1 through January 30. These include programs allowing hospitals to deliver acute care in patients' homes, additional Medicare payments for hospitals with low patient volumes and high senior populations, and continued funding for community health centers, teaching health centers, and the National Health Service Corps. It also delays scheduled Medicare payment cuts, such as those affecting laboratory tests and hospital Medicaid reimbursements.

3. Outlook for Long-Term Legislation: The inclusion of these health policy "extenders" in the short-term continuing resolution may signal a legislative expectation that they will also appear in future, longer-term government funding packages. As noted by policy expert Jeff Davis, this could pave the way for these temporary measures to become part of broader fiscal year funding efforts.

How alternative PBMs are shaking up the industry

By Maia Anderson and Caroline Catherman – A pharmacy benefit manager (PBM) without all the usual drama? It’s a lofty goal. Federal lawsuits and investigations have accused the three largest PBMs—CVS Health’s Caremark, Cigna Evernorth’s Express Scripts, and UnitedHealth Group’s Optum Rx—of overcharging for drugs, pocketing savings, and giving perks to their vertically integrated insurance companies as well as their own specialty and mail order pharmacies. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Alternative PBMs Challenge Traditional Models with Greater Transparency: A new wave of pharmacy benefit managers (PBMs)—including Navitus, AffirmedRx, and Rightway Healthcare—is gaining momentum by offering transparent, fee-for-service business models. These companies differ from traditional PBMs by claiming to pass through 100% of drug manufacturer discounts directly to insurers and patients, avoiding practices like spread pricing. This approach aims to reduce overall drug costs while offering clearer data access and billing practices, which appeals particularly to self-funded employers and public health plans.

2. The Big 3 PBMs Face Scrutiny but Maintain Market Share: The dominant PBMs—Caremark, Express Scripts, and Optum Rx—continue to control a large share of the market and argue that they pass along 95–98% of negotiated discounts to insurers. However, they face increasing scrutiny, particularly from the Federal Trade Commission, which reported that the Big 3 made over $1.4 billion through spread pricing between 2017 and 2022. Allegations of preferential treatment for their vertically integrated pharmacies have added to calls for more transparency and regulatory oversight.

3. Systemic Challenges and Regulatory Pressure Remain: Despite growing interest in alternative PBMs, experts believe these models are unlikely to replace the traditional giants entirely. Their adoption often involves more complex relationships and administrative burdens for clients. Still, pressure is mounting from employers, government plans, and advocacy groups seeking reform. All 50 U.S. states have enacted some form of PBM regulation, with some—like Arkansas—taking aggressive action against vertical integration, though debates persist on whether such integration can be leveraged for efficiency or contributes to unfair market advantages.

As mental health costs rise, benefit managers seek new solutions

By Paola Peralta - Mental health has rapidly emerged as one of the biggest healthcare costs across every industry, pushing employers to expand their take on behavioral health support and well-being benefits. Depression and anxiety already costs the global economy approximately $1 trillion in lost productivity every year, according to the World Health Organization (WHO), and according to recent research from financial services company Mercer, it has also become the second highest driver of organizations' healthcare and medical expenses. Finding more holistic mental health plans and policies should be top of mind for benefit leaders. Read Full Article… ^{_{(Subscription required)}}

HVBA Article Summary

1. Mental health has become a mainstream workplace concern: The stigma around seeking therapy is decreasing, as noted by behavioral health leader Peter Rutigliano, signaling a cultural shift in how mental health is perceived. According to Mercer, nearly 50% of employees globally are worried about their physical, mental, or cognitive health. Stress affects 45% and loneliness impacts 36% of employees on most days at work. Notably, 1 in 4 workers would consider leaving their current employer due to insufficient healthcare or well-being benefits—highlighting the urgency for organizations to prioritize mental health support.

2. Employers are facing economic constraints despite rising demand: Despite strong employee demand for holistic mental health coverage, economic uncertainty is holding many leaders back from implementing more progressive solutions. Innovative mental health programs can be costlier than traditional approaches, and Rutigliano notes that many companies are hesitating to invest due to concerns about the uncertain future. As a result, although only 24% of employers currently offer mental health screenings and about 50% provide counseling, further advancements remain limited by financial caution.

3. Early intervention and culture are critical to long-term success: Encouragingly, 64% of large employers view expanding behavioral healthcare access as a key strategy over the next 3–5 years. Currently, 45% of them either offer or plan to offer care beyond phone or video sessions, and 29% provide or will provide in-person counseling. However, Rutigliano advocates for going further by integrating mental health coaching, education, and even AI tools. He stresses that cultivating a transparent workplace culture and supporting early intervention are vital to improving engagement, reducing turnover, and enhancing productivity.

AHA25: Amgen's Repatha clears 25% mark in preventing first cardiac events

By Anna Bratulic – Detailed results from the VESALIUS-CV trial, unveiled Saturday at the American Heart Association (AHA) Scientific Sessions, show that adding Repatha (evolocumab) to standard cholesterol-lowering therapy cut the risk of a first major adverse cardiovascular event (MACE) by 25% among high-risk patients who had never before suffered a heart attack or stroke. The findings make Repatha — which until now had been used in secondary prevention — the first PCSK9 inhibitor to demonstrate a significant benefit in the primary-prevention setting. Read Full Article...

HVBA Article Summary

1. Clinical Efficacy in Primary Prevention: The Phase III VESALIUS-CV study followed approximately 12,300 patients over a median of 4.5 years and found that Repatha significantly reduced the risk of major adverse cardiovascular events (MACE) by 25% in individuals already on statins or other lipid-lowering therapies. This reduction met and exceeded the 20% threshold that many U.S. physicians consider clinically meaningful for primary prevention, according to a recent survey. Importantly, this was achieved without introducing any new safety concerns.

2. Additional Health Benefits and Subgroup Outcomes: In addition to reducing MACE, Repatha was shown to lower the risk of first heart attacks by 36% and reduce LDL-cholesterol levels to an average of 45 mg/dL — a level well below traditional therapeutic targets. Notably, the drug also showed preventive benefits in people with high-risk diabetes who had no prior cardiovascular events, suggesting its potential utility in broader high-risk populations beyond those with established cardiovascular disease.

3. Regulatory Progress and Commercial Strategy: Since its initial FDA approval in 2015, Repatha has steadily gained expanded indications, including a major label update in August 2024 to encompass adults at increased MACE risk due to uncontrolled LDL cholesterol. With $2.2 billion in sales in 2024 and positive data from the VESALIUS-CV trial, Amgen plans a strong push to raise awareness among primary care physicians, emphasizing Repatha as an effective and affordable add-on to existing lipid-lowering treatments.