ACA marketplace shoppers experience ‘sticker shock’

By Susan Rupe – Congress’ failure to approve extending enhanced tax subsidies is one factor driving higher premiums in the Affordable Care Act marketplace for 2026. Open enrollment for the ACA marketplaces begins Nov. 1 for coverage that starts in January, although some states already have allowed consumers to “window shop” online for plans. Louise Norris, a health policy analyst with healthinsurance.org and medicareresources.org, told InsuranceNewsNet that ACA marketplace shoppers in several states are already getting a preview of what’s to come if Congress allows the enhanced tax credits to expire Dec. 31 — and the early numbers are shocking some consumers. KFF reported that ACA marketplace premiums would more than double next year if enhanced premium tax credits expire. Read Full Article...

HVBA Article Summary

1. Impact of Enhanced Tax Subsidies Expiration: The potential expiration of enhanced premium tax credits at the end of 2025 is expected to cause a significant increase in ACA marketplace premiums for 2026. These enhanced subsidies, introduced in 2021 and extended by the Inflation Reduction Act, have provided increased financial assistance to enrollees, including middle-income individuals previously ineligible. Without these subsidies, premiums could more than double, causing substantial financial strain for many consumers across various states.

2. Insurance Market Dynamics and Risk Pool Changes: The uncertainty surrounding the continuation of enhanced subsidies is influencing insurers' rate-setting decisions. Insurers anticipate that higher premiums will lead healthier individuals to drop coverage, leaving a smaller, sicker risk pool. This adverse selection effect drives premiums even higher, compounding affordability challenges for marketplace enrollees.

3. Insurer Participation and Market Exits: Several insurers are exiting the ACA marketplace or individual markets in various states by the end of 2025, including Aetna, which will cease marketplace coverage in 17 states. Other insurers such as Health Alliance, Quartz, CareSource, Molina, and others are also leaving specific state markets. Additionally, Blue Cross Blue Shield of Arizona is terminating Marketplace PPO plans, requiring affected enrollees to select new plans. These exits may reduce competition and plan options for consumers.

Provider burnout affects patients, quality care

By Allison Bell – The current U.S. health care system is creating stress for the providers, and may be causing stress for the patients, according to new survey results from PwC. The giant accounting and consulting firm looked at the impact of physician burnout recently when it conducted an online health care consumer insights survey. About 69% of the survey participants who had received care in the past 12 months somewhat or strongly agreed with the statement that the providers appeared to be "rushed or pressed for time." Another 61% agreed that the providers seemed to be "distracted or not fully present," and 59% agreed that the providers seemed to be "burned out or exhausted." Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Physician Burnout is Evident and Impacting Care Quality: The PwC survey reveals that a significant majority of patients perceive their healthcare providers as rushed, distracted, or exhausted, with 69% noticing providers pressed for time and 59% observing signs of burnout. This stress among providers correlates with patient experiences of negative care, including 9% reporting incorrect diagnoses. These findings highlight the direct impact of provider burnout on the quality and safety of patient care.

2. Mismatch Between Patient Preferences and Care Delivery Models: Although only 34% of patients prefer receiving care in providers' offices, 72% actually receive care onsite, indicating a substantial gap between patient preferences and current healthcare delivery. PwC identifies this as a fundamental business model problem, suggesting that healthcare organizations need to shift away from reliance on physical offices toward more virtual care options to better meet patient needs and reduce provider stress.

3. Recommendations for Healthcare Modernization: PwC advocates for healthcare organizations to modernize by investing in virtual platforms, AI-driven tools, and retail partnerships, and by redesigning business models around 'care anywhere' rather than 'care onsite.' This approach aims to alleviate provider burnout, improve patient experiences, and align care delivery with evolving consumer preferences. The survey, conducted with over 4,000 U.S. consumers, underscores the urgency for systemic changes in healthcare operations.

GLP-1 brands: Eli Lilly is the new king of weight loss drugs

By Tina Reed – Eli Lilly is poised to leapfrog Novo Nordisk and become the dominant player in an anti-obesity drug market that could reach $150 billion by the end of the decade. Why it matters: The push to develop blockbuster weight loss drugs had been a two-horse race dominated by Novo Nordisk until the maker of Wegovy and Ozempic started backsliding on weaker sales growth. Since then, it's laid off thousands and revised earnings guidance downward. State of play: While Novo leads in sales for the moment, Eli Lilly's dual-agonist injectables have shown better efficacy in clinical trials and are said by doctors and patients to be more tolerable, market analysts say. Read Full Article...

HVBA Article Summary

1. Eli Lilly's Market Ascendancy: Eli Lilly is rapidly overtaking Novo Nordisk as the leading company in the anti-obesity drug market, which is projected to reach $150 billion by the end of the decade. The company’s dual-agonist injectable drugs have demonstrated superior efficacy and tolerability in clinical trials compared to Novo Nordisk’s offerings. Additionally, Lilly has been successful in direct-to-consumer sales and is developing next-generation obesity treatments, including daily oral pills that may be more convenient than injectables.

2. Competitive Landscape and Innovation: While Novo Nordisk currently leads in sales, it faces challenges from Lilly’s innovative pipeline, including two new injectable drugs in trials and an oral GLP-1 drug, orforglipron, expected to be filed for FDA approval by the end of the year. Lilly’s oral drugs do not require fasting, which may provide a competitive advantage over Novo’s oral GLP-1 drugs that require patients to avoid eating or drinking around dosing times. Other major pharmaceutical companies are also entering the obesity drug market, but Lilly and Novo are expected to maintain dominance in the near term.

3. Market Dynamics and Challenges: Despite Novo Nordisk’s recent FDA approvals and acquisitions aimed at expanding its metabolic disease portfolio, investors perceive Lilly’s momentum as overwhelming. Both companies are also engaged in legal actions against compounding pharmacies producing cheaper knock-off versions of their drugs, which affects market share. The future impact of oral GLP-1 drugs on market expansion remains uncertain, with physicians estimating only a fraction of patients may be recommended these treatments, but it still represents a meaningful opportunity.

3 things for consumers to know as Medicare annual open enrollment begins

By Susan Rupe – Medicare’s annual open enrollment began this week with millions of beneficiaries weighing their coverage options for 2026. Louise Norris, a health policy analyst with healthinsurance.org and medicareresources.org, gave a list of issues consumers should consider when looking at coverage for next year. Read Full Article...

HVBA Article Summary

1. Increase in Part D Out-of-Pocket Cap: The annual cap on prescription drug out-of-pocket costs for Medicare beneficiaries will rise from $2,000 in 2025 to $2,100 in 2026, adjusted for inflation. Additionally, most Medicare Advantage plans will introduce deductibles for drugs in higher tiers (3, 4, and 5), with the maximum Part D deductible increasing to $615. Despite these changes, protections like the $35 insulin cap and no-cost coverage for recommended vaccines remain in place.

2. Reduction in Medicare Advantage and Prescription Drug Plan Options: Some insurers, including Elevance, Aetna, and UnitedHealthcare, are scaling back or exiting certain markets, leading to fewer plan options for beneficiaries in 2026. This is primarily a financial decision by insurers based on profitability. Beneficiaries affected by plan discontinuations may qualify for special enrollment periods and guaranteed-issue rights to switch plans or move to Original Medicare.

3. Introduction of Negotiated Drug Prices and Potential Premium Increases: Starting in January 2026, the Inflation Reduction Act enables Medicare to negotiate prices for certain high-cost drugs, which may benefit consumers in the long term. However, premiums might increase because insurers will receive less federal assistance and are allowed to raise premiums by up to $50 per month. Thus, while drug prices may be negotiated down, beneficiaries could still face higher monthly costs.

Industry Voices—Maximizing your benefits investment: Why health insurance literacy is the missing link

By Rachel Walkuski – Employers invest millions each year in health benefits, but how many employees truly understand the full range of what’s available to them? With more than half of insured adults reporting that they find at least one aspect of how their health insurance works difficult to understand, the gap between benefit design and benefit use remains a costly blind spot for employers. When employees don’t understand their coverage, they underutilize preventive care, overutilize emergency services, mismanage chronic conditions and miss opportunities to leverage voluntary benefits. The ripple effects include inflated claims costs, lost productivity and diminished ROI for employers. Read Full Article...

HVBA Article Summary

1. Health Insurance Literacy Gap Impacts Benefit Utilization: Many employees do not fully understand their health benefits, leading to underutilization of preventive care and overuse of emergency services. This lack of understanding also causes mismanagement of chronic conditions and missed opportunities to use voluntary benefits, which collectively increase claims costs and reduce the return on investment for employers. The literacy gap results in employees viewing benefits in isolation rather than as a coordinated system, which diminishes the overall value of the benefits package.

2. Importance of Year-Round, Culturally Competent Education: Effective benefits education requires ongoing efforts throughout the year rather than concentrating all information during open enrollment. Tailoring education to accommodate generational and cultural differences, including using plain language and translated resources, helps employees better understand and engage with their benefits. Employers who proactively plan multiple educational touchpoints see improved employee confidence and utilization of benefits.

3. Combining Digital Tools with Human Support Enhances Engagement: While digital decision-support tools like plan comparison apps and cost estimators are valuable, they are insufficient on their own to drive meaningful engagement. Employees have diverse learning preferences, so combining digital resources with personal guidance such as live Q&A sessions and one-on-one conversations leads to higher engagement. This multi-faceted approach helps employees make informed choices that balance quality and cost, ultimately improving health and financial outcomes.

Employees want to talk to a real person about benefits, Aflac finds

By Laurel Kalser – Employers significantly misjudge how well their benefit offerings are meeting employee demands: While 75% believe their workforce is satisfied with what they offer, only 65% of employees agree, according to Aflac’s 2025-2026 benefits trend report. One noticeable misunderstanding involves communication, spring surveys of 1,002 employers and 2,000 employees across the U.S. found. Nearly 2 in 5 (37%) of employees said they want to talk to a real person to help with benefits enrollment, but only 28% of employers offer this option. Similarly, 32% of employees said they want one-on-one access to a benefit consultant, but only 28% of employers provide it. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Gap in Perception of Benefits Satisfaction: There is a clear disconnect between employers and employees regarding satisfaction with benefit offerings. While 75% of employers believe their workforce is satisfied, only 65% of employees feel the same way. This gap highlights the need for employers to better understand and address employee expectations and concerns about benefits.

2. Communication and Access to Support: Many employees desire more personal interaction when it comes to benefits enrollment and consultation. About 37% of employees want to speak to a real person for help with benefits enrollment, yet only 28% of employers provide this option. Similarly, 32% of employees want one-on-one access to a benefits consultant, but only 28% of employers offer this, indicating a mismatch in communication and support availability.

3. Financial Concerns and Benefits Education: Employers tend to overestimate employees' ability to handle unexpected medical expenses, with 78% believing employees can manage such costs, while 44% of employees say they could not cover $1,000 in unexpected health expenses. Additionally, less than half of employers communicate about benefits throughout the year, and only a third of employees feel they receive ongoing information. Year-round benefits education and clearer communication could improve employee understanding and satisfaction.

Cannabis Access Tied to Lower Opioid Use in Cancer Patients

By Gargi Mukherjee – A national claims analysis found that opening medical or recreational cannabis dispensaries was associated with fewer opioid prescriptions and shorter opioid supplies among commercially insured adults with cancer. Medical cannabis dispensary openings were associated with a reduction of 41.07 patients with opioid prescriptions per 10,000, whereas recreational dispensaries were associated with a smaller but significant decrease of 20.63 patients per 10,000, suggesting cannabis may serve as an alternative for managing cancer-related pain. Read Full Article...

HVBA Article Summary

1. Significant Reduction in Opioid Prescriptions with Medical Cannabis: The study found that the opening of medical cannabis dispensaries led to a notable decrease in opioid prescriptions among cancer patients, with a reduction of 41.07 patients per 10,000 receiving opioid prescriptions. Additionally, the average days' supply of opioids and the number of prescriptions per patient also decreased significantly, indicating that medical cannabis may effectively reduce reliance on opioids for cancer-related pain management.

2. Recreational Cannabis Dispensaries Also Linked to Opioid Use Decline: Although the reductions associated with recreational cannabis dispensaries were smaller than those for medical dispensaries, they were still statistically significant. Prescription rates decreased by 20.63 per 10,000 patients, and both the mean daily supply and number of prescriptions per patient declined. This suggests that recreational cannabis availability may also contribute to lowering opioid use among cancer patients, though to a lesser extent than medical cannabis.

3. Study Limitations and Future Research Needs: The analysis was limited to commercially insured adults and only included recreational dispensary data from four states, which may affect the generalizability of the findings. The authors highlight the need for further research to explore individual-level impacts, underlying mechanisms, and long-term effects of cannabis policies on cancer pain management. Concurrent state policies could have also influenced the results, indicating the complexity of assessing cannabis's role in opioid use reduction.

From paychecks to prevention: The new reality of employee healthcare decisions

By Muhammad Fahmy – The cost of care remains a major concern for employees, many of whom avoid seeking treatment simply because they don't know what they'll have to pay. Uncertainty around medical expenses can lead to delayed care, potentially turning manageable conditions into chronic ones. Without clear information, employees are left to navigate a confusing system on their own. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Shift in Employee Healthcare Cost Preferences: There is a growing trend among employees, especially younger generations like Gen Z, to choose lower paycheck deductions even if it means less comprehensive coverage. This shift prioritizes immediate take-home pay over preparing for potential high out-of-pocket medical expenses. However, many employees remain financially vulnerable, with 26% feeling less prepared for health emergencies than the previous year and 28% having less than $500 saved specifically for such situations.

2. Impact of High Deductible Health Plans and Importance of Education: High deductible health plans (HDHPs) offer lower premiums but can result in significant out-of-pocket costs that cause employees to delay or skip necessary care. Educating employees about preventive services that are typically covered at 100% and guiding them to cost-effective care options, such as freestanding imaging centers, can help mitigate these challenges. Employers can also promote the use of health savings accounts (HSAs) and flexible spending accounts (FSAs) to better manage medical expenses.

3. Value of Continuous Benefits Education: Making benefits education an ongoing, year-round conversation rather than a once-a-year event can improve employee understanding and utilization of healthcare resources. Aligning communications with national health awareness months and offering interactive sessions with experts can personalize and clarify complex benefit topics. Additionally, reinforcing carrier communications and reminders about preventive care can empower employees to make smarter healthcare decisions and prioritize long-term well-being.