"Ways and Means Committee Chairman Jason Smith (MO-08) and Energy and Commerce Committee Chairman Brett Guthrie (KY-02) announced the details for an upcoming hearing with five of the biggest health insurance company CEOs to answer questions on making health care more affordable for all Americans.... The date of the hearing will be January 22, 2025 ... Company CEOs in attendance will be UnitedHealth Group, CVS Health, Elevance Health, The Cigna Group, and Ascendiun (the parent company of Blue Shield of California)." MORE >>
"[T]wo air ambulance providers ... have filed a petition for writ of certiorari with the U.S. Supreme Court ... The petition asks the Court to decide a key question that has divided federal courts across the country: whether the NSA permits providers to bring private causes of action to enforce IDR awards in court. Should the Supreme Court grant cert, the outcome of the case could have broad implications for the enforceability of NSA arbitration awards, a key feature of the NSA's regulatory framework." [Guardian Flight, L.L.C. and Med-Trans Corp. v. Health Care Serv. Corp., No. 24-10561 (5th Cir. June 12, 2025; cert. pet. filed Oct. 8, 2025, No. 25-441)] MORE >>
19 pages. "The need for long-term reforms to Medicare has been repeatedly raised. One is to raise the eligibility age from 65 to the Social Security full retirement age of 67, then tie it to increases in longevity.... In this paper, [the authors] estimate the coverage and spending effects of eliminating Medicare coverage for those ages 65 to 66[.]" MORE >>
"This brief provides an overview of the role of PBMs in managing pharmacy benefits, discusses recent federal legislation focusing on several elements of PBM business practices, and explains the potential federal budgetary impact of this legislation, which would have a relatively modest impact on the federal deficit, based on available CBO estimates." MORE >>
"[T]he Fifth Circuit reversed an award of more than $1.8 million in attorneys' fees under ERISA Section 502(g)(1), holding that a claimant who ultimately obtained no substantive relief cannot recover fees based solely on favorable factual findings or judicial criticism of plan procedures." [Cloud v. Bert Bell/Pete Rozelle NFL Player Ret. Plan, No. 25-10337 (5th Cir. Dec. 18, 2025),] MORE >>
"In the latest survey of leading health care policy scholars ... [most] agreed that proposals to convert enhanced subsidies for [ACA] Marketplace plans into contributions for health savings accounts (HSAs) would have an overall effect of worsening health care affordability for enrollees. There was also consensus that requiring small-dollar premiums (instead of permitting fully subsidized plans with no net premium) would measurably reduce Marketplace enrollment; there was further consensus that a scheduled policy change that will effectively end automatic renewals with subsidy will substantially reduce Marketplace enrollment." MORE >>
"First and foremost is the role that health care affordability will play in the midterms.... Second ... how enrollees actually respond in the Marketplaces.... [S]tates that have expanded Medicaid will be gearing up for Medicaid work requirements, which kick in in 2027 ... [A]fter years of moderate increases ... health costs will increase more sharply again.... [T]he Trump administration has put pressure on drug prices through a variety of initiatives.... [F]our in 10 Americans say they identify in some way with the MAHA agenda." MORE >>
"[Some] are pitching the accounts as an alternative to expiring enhanced federal subsidies that have lowered insurance premium payments for most Americans with [ACA] coverage. But legal limits on how HSAs can and can't be used are prompting doubts that expanding their use would benefit the predominantly low-income people who rely on ACA plans.... One group that would almost certainly benefit: a slew of companies selling expensive wellness items that can be purchased with tax-free dollars from the accounts." MORE >>
"[M]aking patients bear more of their costs out of pocket is a bad way to reduce wasteful health-care spending. It does more to inhibit access to care than to steer patients to cheaper sources of treatment. This is because health-care spending is highly concentrated among the seriously ill, for whom additional expenditures greatly exceed any realistic deductibles. Legislators should instead focus on letting Americans purchase more affordable insurance plans that are better focused on their health needs." MORE >>
December 3 hearing. Video and testimony from witnesses [1] Joel White, Council for Affordable Health Coverage; [2] Marcie Strouse, Capitol Benefits Group; and [3] Claudia M. Fegan, MD, Physicians for a National Health Program. MORE >>
"While gains were made in structuring individual market health plan choices in the ACA, additional standards for plan design, marketing, and enrollment could improve consumer satisfaction and health care affordability. However, progress toward these goals could be undermined by future administrative or congressional changes, such as allowing alternative plan types or rolling back regulations that promote standardization." MORE >>
"Pursuant to ERISA Section 515, duress is among the defenses that cannot be used as a defense in an action by trust funds to collect delinquent contributions. A claim for economic duress may be preempted by ERISA. A violation of ERISA's claims procedures rule could constitute duress.... While duress can be alleged with respect to a designation of beneficiary or with respect to an agreement to arbitrate, or a forum selection clause, it arises most frequently in the employee benefits context in connection with the validity of releases." MORE >>
"Whereas HIPAA only covers healthcare providers, payers and clearinghouses and their business associates that electronically transmit data, Cassidy's HIPRA [S 3097] would address the growing number of consumer apps, wellness platforms and wearables that collect consumer health data such as weight, blood pressure readings, sexual health information or other sensitive health information." MORE >>
"The court determined that ESI's claim that the Act applies only to consumer-oriented acts or practices is a requirement that does not appear in the statute, which was intended to govern the conduct of PBMs, pharmacies, and pharmacists. Additionally, the court found that ESI's interpretation of the statute would render the enforcement mechanism in the Act 'meaningless.' " [Lackie Drug Store, Inc. v. Express Scripts, Inc., No. 23-1669 (E.D. Mo. 2025)] MORE >>
"[J]udges on an Eighth Circuit Court of Appeals Panel briefly questioned the pharmacy benefit managers (PBMs) accused by the [FTC] of artificially inflating insulin prices by rigging the pharmaceutical supply chain in their favor and preventing patients from accessing affordable life-saving drugs. These PBMs are attempting to stop the FTC's internal proceedings against them while the constitutional challenge plays out.... Essentially, the PBMs are arguing that they will be irreparably harmed if their claims are adjudicated in the FTC's internal administrative proceedings instead of federal court." [Express Scripts, Inc., v. FTC, No. 24-1549 (E.D. Mo. Feb. 18, 2025; on appeal to 8th Cir No. 25-1383; oral arg. Nov. 19, 2025)] MORE >>
"[P]roposals have emerged from some Republicans in Congress to effectively repeal some or all of the ACA premium tax credits and replace them with contributions to Health Savings Accounts (HSAs) or something similar." MORE >>
"[A]ny congressional deal on ACA subsidies that might happen this year, or in time to ride on the government spending bill needed by the end of January, might carry [some] employer-backed policies nearly enacted in December 2024. These include bipartisan proposals to ensure greater transparency in the healthcare system, expand site-neutral payment reforms that align payment rates for services across sites where patients receive outpatient care and restrict anti-competitive contracting provisions that limit plan sponsors' flexibility to design high-value plans." MORE >>
"Congress must put small employers at the center of any reform effort. That starts with ensuring they have access to flexible, affordable coverage options, including the ability to self-fund, and expanding and making permanent Association Health Plans so small businesses can band together to negotiate lower costs." MORE >>
"Congress must stop the widespread abuse of the drug patent system that prevents competition and keeps U.S. drug prices far too high.... Site-neutral payment reforms would lower costs and ensure American patients receiving the same service from the same entity in the same geography are charged the same price.... Policymakers should codify existing rules on Individual Coverage Health Reimbursement Arrangements (ICHRAs) to give more employers a predictable mechanism for enrolling workers and their families in affordable health insurance coverage of their choosing." MORE >>
"The United States ... has no mechanism to control overall health spending in our fragmented health system and then to compensate, we micromanage to control costs ... The posterchild of how this happens in the U.S. is prior authorization review, ... [which] is becoming a duel between provider AI tools helping hospitals and large group practices out maneuver insurance company prior authorization, and insurance company AIs trying to weed out necessary from unnecessary care and promote 'value' as well as, of course, insurance company profits." MORE >>
"Tax law changes over the last decade resulted in a smaller role for itemized deductions overall, including the [itemized medical deducsion (IMD)], and concentrated benefits among older, higher-income taxpayers. The IMD could be reformed to better target relief to those with high medical costs in budget-neutral ways. However, alternative policies would likely more effectively protect Americans against uncovered health risks." MORE >>
"[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 >>
