"[T]here will be no decrease in the amount of ERISA litigation as long as the main proponents and beneficiaries of frivolous litigation in this country remain rooted.... Defense lawyers who might sympathize with the plight of their clients have no incentive to curtail baseless lawsuits as it means fees for them ... Big settlements mean big profits [for insurers] since loss ratios determine premium rates.... [S]tate governments get a premium tax from insurance companies as a percentage ... of the premiums written in each state." MORE >>
"PBMs play a powerful role in determining which medications are accessible and affordable. Today, three PBMs process nearly 80% of prescription drug claims in the U.S., giving them immense market power. This consolidation has created a skewed marketplace that drives up drug costs, limits patient choice, and makes it difficult for employers to negotiate contract terms for medications.... These consequences are real, and they are urgent to address." MORE >>
"For years, the conversation around health insurer consolidation and vertical integration has simmered through antitrust inquiries, oversight hearings, and policy papers. The Patients Over Profit Act [HR 5433;S 2836] ... marks a decisive shift. Rather than regulating insurer-provider integration, the POP Act proposes to ban it outright." MORE >>
"[A recent GAO report's] recommendations were structured around five pre-identified areas of potential reform: strengthening primary care; expanding the health care workforce; reforming pricing to better align with high value care; revising Medicare physician payments; and mitigating anticompetitive actions and practices.... [The authors] the areas []they] believe are most critical for policymakers to consider and offer new insights that have gained salience given shifts in the policy landscape since the forum was conducted." MORE >>
"The IDR process should not be exploited as a default pricing mechanism. Guardrails must be implemented to prevent abuse and ensure it remains a last resort. We urge the Departments to adopt reforms that ensure timely, transparent, and predictable resolution of payment disputes to protect plan sponsors and their enrollees." MORE >>
"The current U.S. health system is ill-equipped to respond to the 21st century needs of patients and communities. A health system overhaul is needed to put patients at the center of care, to prioritize health education and disease prevention, to provide care to patients where and when it is most convenient for them, and to leverage technology to do more with less. Reform also should seek to increase access and capacity and curb health care costs." MORE >>
"[SB 41 requires] all PBMs in the state to be licensed by its Department of Insurance and prohibits multiple business practices that have drawn the ire of PBM critics, namely spread pricing arrangements and efforts to steer patients toward affiliated pharmacies. The legislation also mandates that PBMs pass all rebates through to the payer or patient and bars these companies from making exclusivity deals with drugmakers[.]" MORE >>
"Key Takeaways ... [1] Courts may compel insurers to produce documents required under ERISA's own procedural rules.... [2] Plaintiffs must present evidence suggesting the insurer's conflict actually affected the claim decision.... [3] Plaintiffs who tie discovery requests directly to regulatory entitlements, rather than broad fairness concerns, are more likely to succeed." [Gannon v. Hartford Life and Accident Ins. Co., No. 24-1955 (D. Conn. Oct. 3, 2025)] MORE >>
"Employer-sponsored health insurance (ESI) is the largest source of health coverage for non-elderly U.S. residents. ... Providing health insurance through workplaces is an efficient way of offering coverage options to working families, and the tax benefits of employer-based coverage further enhance its attractiveness. Yet, ESI often results in uneven coverage, especially for those with low wages or those working at smaller firms. " MORE >>
"The National Community Pharmacists Association, Iowa Pharmacy Association, American Pharmacists Association and Independent Pharmacy Cooperative filed a friend-of-the-court brief ... arguing that the law is legal and urging the 8th Circuit Court of Appeals to allow it to stand. The groups, which represent independent community pharmacies, say that PBM actions targeted by Iowa's law are driving unaffiliated pharmacies out of business and harming patient access to drugs." [Iowa Assoc. of Bus. and Ind. v. Ommen, No. 25-0211 (S.D. Iowa Jul. 21, 2025; on appeal to 8th Cir. No. 25-2494)] MORE >>
"[E]mployers are navigating unsettled law on whether federal nondiscrimination requirements permit exclusions for gender-affirming care. Plan participants may challenge restrictions under statutes such as ACA §1557 and Title VII. Courts are distinguishing between state laws that restrict available care and federal nondiscrimination mandates that still apply to employer plans." MORE >>
"The [Cunningham v. Cornell] ruling is badly mistaken. Because the definition of 'party in interest' includes every plan fiduciary, the Court's decision allows lawsuits for all transactions involving a plan's receipt of services, even the services mandated by ERISA. On the Court's reading of the statute, ERISA both requires that fiduciaries perform specific acts and simultaneously prohibits fiduciaries from performing those same acts." [Cunningham v. Cornell Univ., No. 23-1007 (S.Ct. Apr. 17, 2025)] MORE >>
"While ERISA claims are indeed arbitrable as a general matter, a growing number of circuit courts have ruled that arbitration clauses cannot overreach and extinguish substantive remedies. Several plan sponsors have tried to add arbitration clauses that waive plan-wide remedies, but courts have found them to constitute prospective waivers of participants' statutory rights, rendering them unenforceable under the 'effective vindication' doctrine." MORE >>
"Aronowitz's appointment signals a potential turnaround in EBSA's regulatory posture, with implications for ongoing litigation, compliance strategies and fiduciary risk management. His leadership is expected to bring a more pragmatic and business-friendly approach to EBSA's enforcement and rulemaking priorities." MORE >>
"Where Illinois [HB 1697] breaks new ground is by assessing an annual fee of $15 per member on PBMs covering participants in the state. The fee is effective starting January 1, 2026, and is intended to fund grants for pharmacies in underserved and low-income areas. This is unlike legislation previously seen in other states." MORE >>
"The newly confirmed Assistant Secretary of Labor and head of the Employee Benefits Security Administration has pledged to streamline retirement plan oversight and end the ‘war on ESOPs.’... During his confirmation hearing, he stressed that he intends to make clear that fiduciaries, not the DOL or plaintiffs’ lawyers, should decide what is best for retirement plan participants." MORE >>
"This article examines how the lack of standardized identifiers for provider networks creates many frustrations for consumers and other health care stakeholders. It also reviews the role that standardized identifiers and standards bodies play in developing seamless consumer experiences in other industries and the roles the could play in health care in assisting consumers and other stakeholders." MORE >>
"Anna Lange ... sought a male-to-female sex change surgery and requested that the County's employer-provided health insurance pay for it. But because the County's insurance policy excludes '[d]rugs for sex change surgery' and '[s]ervices and supplies for a sex change and/or the reversal of a sex change,' the insurer denied Lange's request.... Lange then sued the County for disparate treatment because of sex under Title VII of the Civil Rights Act of 1964 ... We took this appeal en banc to answer whether the insurance policy facially violates Title VII. We conclude that it does not." [Lange v. Houston County, Georgia, No. 22-13626 (11th Cir. Sep. 9, 2025)] MORE >>
"This Congress, these reforms have been reintroduced in one legislative package in the House as HR 4317, the PBM Reform Act and two companion measures in the Senate as S 927, the Protecting Pharmacies in Medicaid Act, and as S 882, the Patients Before Middlemen Act.... This legislation ... would lower drug costs ... would support pharmacies' ability to serve patients ... and would shine a light on PBM practices by requiring transparency from the corporations that have persistently resisted it." MORE >>
"[A]dding ESI would raise payroll taxes by about $400 per year on average and reduce Social Security's 75-year shortfall by about 25 percent. This option is somewhat regressive -- as it would collect no additional taxes from earners above the wage cap -- but it could be part of a larger reform package." MORE >>
"[T]he state of West Virginia ... filed a federal court action against pharmacy benefit manager (PBM) Express Scripts Inc. (ESI) based on its alleged role in manipulating and exacerbating the opioid overdose epidemic. The West Virginia attorney general asserts that ESI, as a PBM, held a 'uniquely powerful position' within the 'prescription drug ecosystem.' " [West Virginia v. Evernorth Health, Inc., No. 25-0182 (N.D.W.V. complaint filed Aug. 15, 2025)] MORE >>
"The Fifth Circuit has now sent the case back to the trial court ... In so doing, the court specifically noted that its prior opinion directed the trial court to address the 'compelling -- and largely unrebutted -- arguments' raised on appeal that HRSA and ACIP members were appointed in a manner that violated the Administrative Procedure Act." [Kennedy v. Braidwood Management, Inc., No. 24-316 (S. Ct. Jun. 27, 2025; 5th Cir. No. 23-10326 remanded Aug. 26, 2025)] MORE >>
"The Sixth Circuit recently addressed whether 'equitable relief' under ERISA includes the remedy of 'surcharge.' Following a 2023 decision from the Fourth Circuit, the Sixth Circuit concluded that it does not. The courts reached this conclusion by engaging in an analysis that more litigants and courts should be conducting in ERISA cases." [Aldridge v. Regions Bank, No. 24-5603 (6th Cir. Jul. 17, 2025)] MORE >>
"This report provides information on selected health provisions that have expired or are scheduled to expire during the 119th Congress (i.e., calendar years 2025 and 2026). For purposes of this report, expiring provisions are defined as portions of law that are time-limited and will lapse once a statutory deadline is reached, absent further legislative action. The expiring provisions included in this report are any identified provisions related to Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), or private health insurance programs and activities." [R48649 Aug. 27, 2025] MORE >>
"To date, courts have rejected constitutional challenges to the law, preserving the law's fundamental protection against surprise out-of-network bills. But other lawsuits have taken a toll as providers have largely been successful in blocking key rules and guidance to implement the IDR process.... Most recently, payers have turned to the courts to sue providers and IDR middlemen, alleging widespread abuse of the IDR process by several private equity-backed firms that initiate many IDR disputes." MORE >>
