The cost of health insurance for a family jumps to $27,000

By Tara Bannow – Premiums for employer-provided health insurance spiked by more than double the rate of inflation this year, driving the cost of a family plan to almost $27,000, a new survey finds. KFF’s annual survey of more than 1,800 small and large employers found family premiums grew 6% in 2025, compared with a 7% increases in each of the previous two years. That’s compared with general inflation of 2.7% and wage growth of 4% over the past year. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Rising Employer Health Insurance Premiums Expected in 2026: While the KFF report does not project exact figures for 2026, other industry surveys indicate that employer-sponsored health insurance premiums could rise by approximately 9%. These increases are driven by multiple factors, including higher hospital prices, the growing use of expensive GLP-1 drugs for weight loss and diabetes, tariffs, and broader inflationary pressures. Industry experts warn that these trends signal a significant uptick in costs for both employers and employees in the coming year.

2. Cost Burden Increasing for Both Employers and Employees: Health insurance costs for families covered through employer plans have climbed steadily, with the average annual premium reaching nearly $27,000 in 2025—an increase of $1,408 from the previous year. Of that amount, employees pay about $6,850 while employers cover the remaining $20,143. Additionally, workers face growing out-of-pocket costs, as the average deductible for individual plans has risen to nearly $1,900. These trends suggest that employees may continue to shoulder a greater share of healthcare expenses moving forward.

3. Coverage Quality Varies by Employer Size and Strategy: Larger employers, particularly those with 5,000 or more workers, are more likely to offer comprehensive health benefits, including coverage for high-cost medications like GLP-1s used for weight loss. These organizations also typically contribute a greater portion of total healthcare costs. In contrast, smaller firms often struggle to provide robust coverage due to limited bargaining power and smaller risk pools. However, benefit quality is not solely determined by company size—it also depends on internal factors such as company structure, geographic location, and how much emphasis the HR department places on employee healthcare.

Time crunch poses obstacle to ACA talks

By Peter Sullivan – It may already be too late to implement certain changes Republicans are insisting on as a condition for renewing to Affordable Care Act subsidies, further casting doubt on any congressional deal to extend the financial aid. Why it matters: GOP lawmakers have made clear that they need to see changes to the enhanced ACA tax credits at the center of the government shutdown fight in order to extend them. But insurers, states and other experts say some changes could already be impossible for next year, with ACA enrollment due to begin in less than two weeks, on Nov. 1. The subsidies are due to expire at year's end, absent further action. Read Full Article...

HVBA Article Summary

1. Time Constraints Limit Implementation of GOP Changes: Experts and industry insiders indicate that the timeline to implement significant changes to the ACA tax credits before the November 1 open enrollment period is extremely tight. This makes it unlikely that major modifications, such as capping eligibility or requiring minimum premium payments, can be operationalized in time for the 2026 enrollment year. Consequently, this time crunch casts doubt on the feasibility of Republican demands as a condition for subsidy renewal.

2. Potential Workaround and Industry Recommendations: One proposed solution is to extend the enhanced ACA subsidies unchanged for the 2026 year, allowing immediate coverage and tax credit updates, with any GOP-driven changes taking effect in 2027. Insurance industry sources and marketplace officials suggest that this approach minimizes risk and operational challenges. This compromise could provide continuity for enrollees while allowing lawmakers more time to negotiate substantive reforms.

3. Political Stalemate and Negotiation Challenges: Congressional Democrats urge Republicans to engage in negotiations to avoid subsidy expiration and a government shutdown, but Republicans insist that reopening the government must come first. The ongoing shutdown since October 1 has stalled discussions, complicating efforts to reach a timely agreement. Additionally, contentious issues such as language preventing subsidies from funding elective abortions add complexity to the negotiations, further delaying progress.

Orphan drugs' price negotiation exemption to cost Medicare $8.8B

By Dave Muoio – A provision of the summer’s One Big Beautiful Bill Act bumping a slew of orphan drugs from Medicare price negotiation is estimated to cost the program $8.8 billion over the course of a decade, according to a revised estimate from the nonpartisan Congressional Budget Office. That tally is about $3.7 billion higher than the CBO’s estimate over the summer, which did not include three drugs that the office now believes would be eligible—Darzalex (daratumumab), Keytruda (pembrolizumab) and Opdivo (nivolumab). Read Full Article...

HVBA Article Summary

1. Significant Cost Increase Due to Expanded Exemptions: The Congressional Budget Office's revised estimate shows that the expanded exemption for orphan drugs under the One Big Beautiful Bill Act will cost Medicare $8.8 billion over ten years, which is $3.7 billion more than previously estimated. This increase is mainly due to the inclusion of three additional drugs—Darzalex, Keytruda, and Opdivo—that are now considered eligible for exemption from price negotiation. The cost could vary between $6.7 billion and $10.9 billion depending on how the Centers for Medicare and Medicaid Services (CMS) treat different drug formulations.

2. Political and Industry Reactions: Democratic lawmakers criticized the expanded exemption as a "sweetheart deal" for pharmaceutical companies that undermines efforts to lower drug prices for seniors. They argue that the legislation weakens Medicare's ability to negotiate drug prices and contributes to broader healthcare funding challenges. Conversely, the pharmaceutical industry and CMS defend the exemptions, stating they are necessary to incentivize ongoing research and development of treatments for rare diseases, which still lack approved therapies for over 90% of cases.

3. Implications for Drug Pricing Policy: The expanded orphan drug exemption highlights the tension between controlling drug costs and encouraging pharmaceutical innovation. Consumer advocacy groups and policy researchers have called for repealing or limiting the exemption, citing its high cost and impact on patients and taxpayers. Meanwhile, CMS has introduced guidance to implement these changes and plans to include Medicare Advantage spending in future drug price negotiations, which may affect the scope and impact of price negotiation policies going forward.

Up to 99% of behavioral health listings in some health plan directories are 'ghosts'

By Allison Bell – The percentage of "ghost providers" in U.S. health plans' behavioral health provider directory sections varies widely from plan to plan but is often high. Officials at the U.S. Health and Human Services Office of the Inspector General have published data supporting that conclusion in a report on the results of a review of 52 plans' provider directories. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. High Inaccuracy in Provider Directories: A substantial number of behavioral health provider directories in Medicare Advantage and Medicaid plans were found to be inaccurate, with inactive provider listings ranging from 8.8% to as high as 99.2%. Notably, one plan had only 3 active providers out of 356 listed. Additionally, over one-third of the reviewed plans had more than 33% of their providers classified as inactive, highlighting a widespread issue with directory reliability.

2. Proposal for a National Provider Directory: The HHS Office of Inspector General recommended that the Centers for Medicare and Medicaid Services (CMS) explore the development of a centralized National Directory of Healthcare Providers and Services. This directory would be regularly updated and include both contact information and insurance participation details. The goal is to improve access to accurate provider data for patients, while also supporting insurers, employers, and network administrators in maintaining up-to-date directories.

3. Concerns and Challenges from Stakeholders: While a national directory could streamline access to accurate information, it has sparked mixed reactions. Some provider organizations, such as the American Hospital Association, worry that the added requirements could further increase the administrative burden on healthcare providers. At the same time, broader systemic challenges remain, including low reimbursement rates and administrative complexity, which make it difficult to recruit behavioral health providers and ensure that directory information stays current.

It’s Time to Rethink Prior Authorization for Chronic and Serious Conditions - MedCity News

By Matt Cunningham – A breast cancer diagnosis should trigger immediate action. But for many patients, the journey to treatment begins with delays, often caused by outdated prior authorization (PA) processes. Designed to ensure appropriate care, antiquated prior authorizations slows treatment, frustrates providers, and erodes patient trust. The problem is both technical and clinical. Because the system relies on phone calls, faxes and human intervention, care is delayed or abandoned, and patients and their families suffer. Read Full Article...

HVBA Article Summary

1. Inefficiencies in Current Prior Authorization Processes: The existing prior authorization system relies heavily on manual processes such as phone calls and faxes, which cause significant delays in patient care. These delays can lead to treatment abandonment and increased frustration among providers, ultimately eroding patient trust. The system’s inefficiency detracts from the healthcare goal of delivering timely and appropriate care.

2. Care Pathways as a Solution: Guideline-directed care pathways offer a more efficient alternative by shifting from transactional prior authorizations to an episode-of-care model. This approach uses clinical-first AI and workflow automation to pre-approve a set of services based on evidence-based guidelines once a diagnosis is confirmed. This reduces administrative friction, speeds up care delivery, and maintains clinical flexibility through exception management for cases that deviate from standard pathways.

3. Broader Applicability Beyond Breast Cancer: While breast cancer is highlighted as a starting point, the care pathway model is applicable to other cancers like prostate and colorectal, as well as chronic conditions such as congestive heart failure, sickle cell disease, inflammatory bowel disease, and chronic kidney disease. These conditions have predictable, evidence-based treatment protocols where prior authorization often causes unnecessary delays, making the pathway model both a logical and ethical improvement for patients, providers, and payers.

Pharmacy-based care can increase access, reduce costs

By Alan Goforth – Pharmacy-based care offers practical solutions to workforce health challenges while significantly reducing spending for employers, a new report from the Health Action Alliance found. “Employers need to control health care spending and increase access to care without shifting more costs to workers," said Steven C. Anderson, president of the National Association of Chain Drug Stores, which commissioned the report. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Positive Employee Perception and Convenience: Nearly 9 in 10 U.S. workers view pharmacy-based care positively, with 7 in 10 believing it would improve their health. Many employees find pharmacy visits more convenient than seeing a primary care doctor, with 62% preferring pharmacies for care. Additionally, a significant portion of employees trust pharmacists to diagnose and treat routine illnesses, highlighting the potential for pharmacies to improve access to care.

2. Employer Recognition and Support: A majority of employers recognize the benefits of pharmacy-based services, with 73% believing these services can reduce employees' out-of-pocket costs. Convenience factors such as location accessibility and extended hours are highly valued, with 92% and 89% of employers respectively citing these as key advantages. More than half of employers are open to expanding pharmacy options in their benefits packages, indicating growing support for integrating pharmacy care into employee health strategies.

3. Cost Savings and Healthcare Impact: Pharmacy-led chronic disease management programs have been shown to significantly reduce hospital admissions and emergency visits, contributing to lower overall healthcare costs. With 96.5% of Americans living within 10 miles of a pharmacy and many lacking adequate primary care access, pharmacies provide an existing infrastructure to address healthcare gaps. Studies suggest that pharmacy-based hypertension care alone could save the healthcare system trillions of dollars over the next three decades, underscoring the economic potential of pharmacy-based care.

Savvy Senior

By Jim Miller – Dear Savvy Senior, My husband and I have been thinking about getting a long-term care insurance policy, but we hate the idea of paying expensive monthly premiums for a policy we may never use. Is long-term care insurance worth it? Approaching Retirement Dear Approaching, There are two key factors you need to consider that can help you determine if purchasing a longterm care (LTC) insurance policy is a smart decision for you and your husband. One factor is your financial situation and second is your health history. Currently, around 7.5 million Americans own a policy. Read Full Article...

HVBA Article Summary

1. Cost and Coverage Considerations: Long-term care (LTC) insurance can be expensive, with premiums for a couple aged 65 ranging from $7,137 to $8,493 annually for a benefit pool of $165,000 each including a 3 percent inflation rider. The national median cost for nursing home care exceeds $100,000 per year, while assisted living and home care average over $65,000 annually. Most people pay for LTC through personal savings, Medicaid after savings depletion, or LTC insurance, making it important to weigh the cost against potential benefits.

2. Who Should Consider LTC Insurance: LTC insurance is most suitable for individuals with investable assets between $500,000 and $2 million who want to protect their wealth. Those with fewer assets may deplete their resources and rely on Medicaid, while wealthier individuals can likely afford care without insurance. Personal health, family history of dementia or disability, and longevity also influence the decision, as these factors affect the likelihood and duration of needing long-term care.

3. Types of LTC Insurance and Alternatives: There are traditional LTC insurance policies, which are 'use it or lose it,' and hybrid policies that combine LTC coverage with life insurance benefits, offering a death benefit if care is not needed. Another option is an income annuity with an LTC rider, which increases payouts if care is required but may not cover full costs and can reduce standard payouts. Comparing quotes from multiple sources and considering workplace options can help find the best policy.

Dental benefits are the key to comprehensive menopause care

By Paola Peralta – Menopause is more than hot flashes and fatigue, it could also adversely impact women's oral health. Eighty-three percent of women over 40 say they are not aware of any oral health symptoms brought on by menopause, according to a recent survey released by insurance provider Delta Dental Insurance Company. Yet, many are unknowingly experiencing them. Adding more comprehensive dental benefits could be the next step in making menopause care successful. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Lack of Awareness of Menopause-Related Oral Health Issues: A significant majority of women over 40, 83%, are unaware of oral health symptoms linked to menopause, despite many experiencing issues such as dry mouth, tooth sensitivity, and changes in taste. This gap in awareness highlights the need for better education and resources to support women's oral health during menopause. Insurance coverage that includes menopause-specific dental benefits could encourage women to seek necessary care and information.

2. Impact of Menopause on Oral Health and Workforce: Hormonal changes during menopause can lead to 'menopause mouth,' affecting oral tissues and increasing risks of tooth decay and loss. These oral health challenges can have broader implications for women's overall health, productivity, and well-being in the workplace. Employers who provide comprehensive dental benefits that address these issues demonstrate support for female employees and may improve retention and recruitment.

3. Next Stage Women's Health Program: In response to these needs, Delta Dental plans to launch the Next Stage program in 2026, targeting oral health needs at different life stages, including menopause. The program will offer enhanced dental benefits such as additional cleanings and exams, combined with virtual health services providing education and resources. This initiative aims to close the care gap and promote proactive oral health management among women, ultimately improving health outcomes and workforce support.