Shopping for ACA health plans this open enrollment? Here's what to know

By Michelle Andrews – This year's Obamacare open enrollment period, which starts Saturday in most states, is full of uncertainty and confusion for the more than 24 million people who buy health insurance through the federal and state Affordable Care Act marketplaces. The fate of the enhanced premium tax credits that make coverage more affordable for 92% of enrollees remains up in the air, with the prospect of significantly higher premiums looming. But there are steps marketplace shoppers can take to ensure they make the right choices for the upcoming plan year. Read Full Article...

HVBA Article Summary

1. Uncertainty Over Enhanced Subsidies: The future of enhanced premium tax credits for ACA marketplace plans is uncertain, as Congress has not yet decided whether to extend them beyond 2025. This uncertainty could result in significantly higher premiums for many enrollees if the credits expire. Consumers are advised to stay informed about legislative developments, as changes could occur at any point during the open enrollment period.

2. Importance of Actively Reviewing and Updating Information: Shoppers are encouraged to log in to their marketplace accounts and update their income and household details, rather than relying on automatic reenrollment. Due to recent legislative changes, individuals who underestimate their income may be required to repay the full excess premium assistance they receive. This makes it especially important to provide accurate information and carefully review plan options for the coming year.

3. Premium Increases and Alternative Plan Options: Health insurance premiums on the ACA marketplaces are projected to rise by an average of 26% next year, the largest increase since 2018. Without the enhanced tax credits, many families may face much higher out-of-pocket costs, prompting some to consider less generous plans like bronze or catastrophic coverage. While these plans have higher deductibles, they still provide essential benefits and may be preferable to going uninsured if affordability is a concern.

Patients Go Without Treatment After Government Shutdown Disrupts Telehealth

By Associated Press – Bill Swick has a rare degenerative brain disease that inhibits his mobility and speech. Instead of the hassle of traveling an hour to a clinic in downtown Chicago to visit a speech therapist, he has benefited from virtual appointments from the comfort of his home. But Swick, 53, hasn't had access to those appointments for the last month. The federal government shutdown, now in its fifth week, halted funding for the Medicare telehealth program that pays his provider. So, Swick and his wife are practicing old strategies rather than learning new skills to manage his growing difficulties with processing language, connecting words, and pacing himself while speaking. Read Full Article...

HVBA Article Summary

1. Impact of Government Shutdown on Telehealth Services: The ongoing federal government shutdown has halted funding for the Medicare telehealth program, causing many patients, especially those with degenerative diseases, to lose access to virtual medical appointments. This disruption forces patients and caregivers to revert to less effective, older methods of care, potentially hindering progress in managing chronic conditions. The shutdown has left providers uncertain about reimbursement, leading some to suspend telehealth services for Medicare patients.

2. Significance of Telehealth for Vulnerable Populations: Telehealth has been a critical resource for millions of Medicare fee-for-service beneficiaries, particularly older adults and those with mobility challenges, allowing them to receive specialist care from home. The pandemic-era expansion of telehealth coverage removed geographic restrictions and enabled patients to connect with providers remotely, improving access and convenience. The pause in telehealth funding threatens continuity of care, which is vital for patients with conditions like dementia and other degenerative diseases.

3. Varied Responses from Medical Providers and Policy Challenges: Medical providers are responding differently to the funding lapse; some continue telehealth services at financial risk, while others have stopped offering virtual visits to Medicare patients. Major hospitals and small practices alike face challenges in balancing patient care needs with financial viability. Experts suggest that a simple congressional vote to renew telehealth waivers could resolve the issue, but political stalemates make such action unlikely in the near term, prolonging uncertainty for patients and providers.

Employers 'hungry for ideas' to hold down health claims without cutting coverage

By Allison Bell – Employers are worried about the rising cost of health coverage, and they are hungry for ideas about ways to hold claims down without eliminating benefits, according to J. Powell Brown, the chief executive officer of Brown & Brown. Brown & Brown, a big insurance and benefits advisor, is getting many questions about ideas for managing the costs of claims for high-cost claimants, coping with the high cost of very expensive " specialty" drugs, and improving "population health" efforts, such as efforts to address conditions such as obesity and high blood pressure, Brown said. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Employers Seek Cost-Management Strategies Without Reducing Benefits: Employers are actively looking for innovative ways to control rising health claims costs while maintaining the quality and breadth of coverage for their employees. This includes managing expenses related to high-cost claimants and specialty drugs, which are significant drivers of overall health plan costs. The challenge lies in balancing cost containment with preserving valuable benefits that employees rely on.

2. Focus on Population Health Initiatives: There is an increased emphasis on improving population health through targeted efforts addressing chronic conditions such as obesity and high blood pressure. These initiatives aim to reduce long-term health care costs by improving overall employee health and preventing expensive medical claims. Employers and advisors like Brown & Brown are exploring creative approaches to enhance these programs as part of cost management strategies.

3. Economic Stability Influences Employer Health Plan Decisions: According to J. Powell Brown, the current economic environment is relatively stable, with some industries hiring and others remaining flat. This stability allows some employers to consider maintaining or even enhancing health benefits despite rising costs. However, the pressure to manage expenses remains, prompting ongoing discussions about delivering value to employees while controlling health care spending.

Eli Lilly’s weight loss and diabetes drug tops Keytruda as world’s best-selling medicine

By Elaine Chen – Merck, which has claimed bragging rights as the maker of the world’s best-selling drug, Keytruda, since 2023, has officially been surpassed by Eli Lilly. Lilly’s tirzepatide, marketed as Mounjaro for type 2 diabetes and Zepbound for obesity, saw $10.1 billion in sales in the third quarter, the pharma giant said Thursday, bringing year-to-date sales of the product to $24.8 billion. Merck, meanwhile, reported that Keytruda, a cancer immunotherapy, earned $8.1 billion in the third quarter, bringing year-to-date sales to $23.3 billion. Read Full Article... ^{_{(Subscription required)}}

HVBA Article Summary

1. Tirzepatide Surpasses Keytruda in Sales Projections: Tirzepatide has rapidly ascended to become the world’s top-selling drug, with analysts projecting $32.2 billion in annual revenue — surpassing Keytruda’s expected $31.8 billion. This shift is particularly striking given tirzepatide’s recent approvals for diabetes (2022) and obesity (2023), compared to Keytruda’s nine-year climb to the top. The data reflects an exceptionally fast market adoption for a relatively new entrant.

2. GLP-1 Drug Market Intensifies Amid Strong Demand: The rapid success of tirzepatide highlights the explosive demand for GLP-1-based treatments targeting obesity and diabetes. While Novo Nordisk pioneered this space with its popular drugs Ozempic and Wegovy, Eli Lilly’s tirzepatide is now broadly seen as offering superior weight loss results, effectively shifting competitive dynamics. This signals a new phase of high-stakes rivalry within the rapidly expanding obesity drug market.

3. Eli Lilly’s Financial Performance and Competitive Pressure: Eli Lilly exceeded market expectations with $17.6 billion in third-quarter revenue, well above the $16.1 billion forecast. The company responded by raising its full-year sales guidance to as high as $63.5 billion and increasing its adjusted earnings per share forecast. At the same time, the competitive landscape is heating up, as seen in Novo Nordisk’s aggressive move to acquire Metsera — a biotech company that was previously engaged in acquisition talks with Pfizer — signaling intensifying efforts to secure dominance in the obesity treatment space.

Health plan price transparency still needs work, report finds

By Caroline Catherman – Wouldn’t it be nice if every patient could walk into a hospital and know exactly how much they’ll need to pay? It sure would. But we’re not there yet. Price transparency legislation took effect for hospitals and health plans in 2021 and 2022, respectively, requiring them to publish previously proprietary negotiated rates for all medical services in clear, machine-readable files. Read Full Article...

HVBA Article Summary

1. Widespread Conflicting Rates Among Payers: The Turquoise Health report found that out of 97 payers analyzed, 28 provided conflicting rates for the majority of services, making it challenging for consumers to understand actual costs. For example, Aetna listed conflicting rates for 57% of its services, a much higher percentage than UnitedHealthcare and Cigna, which both had 6%, and Anthem at 16%. This prevalence of inconsistent pricing data undermines the effectiveness of transparency regulations and continues to create confusion for patients.

2. Technical Errors and Data Accessibility Issues Are Less Common but Still Present: The report identified that only about 10% of payers were flagged for having an excessive number of outlier prices, such as clear pricing mistakes, and less than 10% were flagged for having files that could not be parsed. While these issues are not as widespread as conflicting rates, they still present barriers to fully transparent and usable pricing information. Ensuring that machine-readable files are both accurate and accessible remains a necessary step for achieving the goals of price transparency.

3. Accurate Payer Data Is Critical for Determining Patient Costs: Experts emphasize that insurers are responsible for creating the algorithms that convert negotiated rates into the actual prices paid by patients and employers. The report suggests that combining data from both hospitals and payers, along with reference data from claims, Medicare, and Medicaid, can help address information gaps. Recent federal updates to technical requirements for payer data files, finalized in October 2025 and required by February 2026, are intended to improve the accuracy and usability of this information.

CVS Health forecasts double-digit earnings growth in 2026 as it pivots Oak Street Health strategy

By Heather Landi – Buoyed by a rebound in its Aetna business and strong growth in its Caremark pharmacy benefit management segment, CVS Health is forecasting double-digit earnings growth in 2026, executives told investors and analysts Wednesday. Brian Newman, executive vice president and chief financial officer, said the healthcare giant expects mid-teens percentage growth for adjusted earnings per share next year. “We are encouraged by the year-to-date performance of our diversified enterprise and are confident we are taking the right steps to position us for both near and long-term success,” Newman said during CVS Health’s third-quarter earnings call. Read Full Article...

HVBA Article Summary

1. Robust Revenue and Earnings Growth Surpass Expectations: CVS Health achieved a 7.8% increase in third-quarter revenue, reaching $102.9 billion and surpassing analyst forecasts. Adjusted earnings per share rose to $1.60, up from $1.09 the previous year, and the company raised its full-year 2025 earnings guidance to between $6.55 and $6.65 per share. Despite recording a $5.7 billion impairment charge and an operating loss of $3.2 billion in the quarter, CVS Health generated $7.2 billion in year-to-date cash flow from operations and expects 2025 revenue to reach $397 billion, up $6 billion from prior projections.

2. Strategic Shifts in Oak Street Health and Pharmacy Segments: CVS Health is closing 16 underperforming Oak Street Health clinics and slowing expansion, following a $5.7 billion goodwill impairment charge tied to this business. The company grew Oak Street from 169 to about 230 locations since acquiring it in 2023, but is now focusing on improving financial performance through investments in technology and leadership. In its Caremark pharmacy benefit management business, CVS secured nearly $6 billion in new contracts with retention rates in the high nineties, while transitioning to the TrueCost pricing model to enhance transparency and lower drug costs.

3. Aetna's Strong Recovery and Medicare Advantage Ratings: The Aetna insurance segment saw a 9.1% revenue increase in the third quarter, reaching nearly $36 billion, and its medical benefit ratio improved to 92.8% from 95.2% a year earlier. Adjusted operating income for this segment rebounded to $314 million after a loss of $924 million the prior year, driven by favorable regulatory impacts and improved government business performance. Over 81% of Aetna Medicare Advantage members are now in plans rated 4 stars or higher for 2026, and more than 63% are in 4.5-star plans, although total medical membership declined by 445,000 year-over-year due to decreases in individual exchange and Medicare lines.

Study: US obesity rates are dropping as GLP-1 use increases

By Matty Merritt – Gallup released a survey this week showing that the obesity rate among US adults has fallen to 37% this year, a significant drop from the record high of nearly 40% just three years ago. The decline comes as a growing number of Americans turn to GLP-1 drugs to lose weight. Gallup found that the use of these drugs specifically to lose weight (they’re also used to treat diabetes) has more than doubled from February 2024, when it was 5.8%, to 12.4% currently: - More women (15.2%) are taking the drugs than men (9.7%), which correlates with a slightly larger decline in obesity rates among women. - Adults in the 50-64 age range who took the survey had the highest usage of GLP-1s for weight loss, at 17%. Read Full Article...

HVBA Article Summary

1. Significant Decline in US Obesity Rates: The obesity rate among US adults has decreased from nearly 40% to 37% over the past three years. This marks a notable shift in public health trends and suggests that efforts to combat obesity may be having an impact. The decline is particularly evident among women, who have a higher usage rate of GLP-1 drugs for weight loss.

2. Rapid Increase in GLP-1 Drug Usage: The use of GLP-1 drugs, which are primarily used to treat diabetes but have gained popularity for weight loss, has more than doubled since early 2024. Currently, 12.4% of surveyed adults report using these drugs for weight loss, with the highest usage among adults aged 50-64. This rapid adoption highlights the mainstream acceptance and perceived effectiveness of GLP-1 medications in managing obesity.

3. Competitive Pharmaceutical Market for Obesity Drugs: The obesity drug market is highly competitive and expected to reach $150 billion by 2030. Companies like Eli Lilly and Novo Nordisk are aggressively expanding their market share through new drug offerings and strategic partnerships. Notably, Novo Nordisk made a $9 billion unsolicited bid to acquire Metsera, a developer of new GLP-1 drugs, illustrating the high stakes and rapid innovation in this sector.