We designed them to be a great time, but our Bubbles + Benefits events mean a lot more than camaraderie, snacks, and wine and mocktail tastings. This season’s theme—Policies, Pitfalls, and Planning Ahead—tapped into the uncertainty around an administration that continues to deliver detours and twists. With the expiration of enhanced health insurance premium subsidies looming, presenters anticipated the federal government shutdown at our earlier event and addressed it at the third, which happened to fall on Day 1.  

Bubbles + Benefits delivered legislative updates and covered shifting PBM regulations, how to capitalize on biosimilars, and the ways pharmaceutical supply chains create opportunity for employers. Here are some of the highlights.

“What you think is happening in DC is happening,” said Joel Kopperud, senior vice president, government affairs, for The Council of Insurance Agents and Brokers. “The environment is highly polarized, very partisan, and [budget] reconciliation is the only way to pass anything.” 

And to budget reconciliation process we owe the passing of the “One Big Beautiful Bill Act,” (OBBBA) which, among other things, permanently extended the HSA-compatibility of telehealth services and permits pairing with direct primary care arrangements, and increased limits for dependent care assistance programs. OBBBA also passed on PBM reform that would require broad transparency, instead limiting reform to Medicaid transparency and eradicating spread pricing for Medicaid. Meanwhile, states are continuing to churn out bills to address PBM reform; more to come. 

OBBBA did not address the temporarily expanded ACA premium subsidies, which are set to expire at the end of 2025. Kopperud noted the short-sightedness of failing to extend the enhanced subsidies, pointing out that “Cost-shifting is a real thing; the uninsured still get sick, and they’re still going to go to the hospital. Someone has to cover those costs.”  

“Passing the subsidies originally led to the lowest rate of uninsured people in the country”, Kopperud said. However, as we learned in the days following the event, this failed to motivate those opposed, wherein disagreement over this very issue fueled a shutdown of the federal government.

“Trump accounts,” a new tax-advantaged investment account for children under 18, encourages early retirement savings and can bring significant long-term growth. A Trump account will be treated like a traditional IRA for withdrawal purposes, and for parents of kids born during the second Trump administration, there’s an extra incentive: any new Trump account will receive a tax-free payment of $1,000 from the federal government.  

The accounts are available to any American child with a social security number, and parents can (but don’t have to) make additional contributions of up to $5,000 per year—$2,500 of which can come tax-free from a parent’s employer.  

“Take advantage of these accounts,” Kopperud said. And no doubt some employers are considering how to enhance their compensation packages by contributing to these accounts, but there still remain many unknowns to flesh out with future rulemaking.

In a conversation among The MJ Companies experts Bryan Gross, vice president, legal and compliance, Chris Antypas, lead pharmacy consultant, and Anu Dhamecha, directory, pharmacy practice, PBM transparency was the premier topic. Among the challenges noted:  

“Drug costs keep going up, and when you’re paying for that $300,000 cancer drug, part of what you’re paying for is innovation, but the other part is waste,” Dhamecha said. “And depending on your PBM, you might be paying $150 or $800 for the same drug.” 

The crux of the issue, Antypas said, is that “it’s a cash grab,” especially where J-codes are concerned. And although J-codes are particularly ripe for “egregious practices,” without transparency, pricing is a challenge to track—but when it is, the results are bracing. When the FTC looked into 2,000 mail order prescriptions, Gross noted, 51 of those drugs came in at a harrowing 7.5 times National Average Drug Acquisition Cost (NADAC).  

Community-based pharmacies help address some of the cost issues by bringing services together and enabling medication optimization that not only helps support the patient but works toward accountability and efficacy by more closely monitoring drug impact. 

Conversations between employer and PBM are a start, Antypas said, “but there’s a larger supply chain issue,” and addressing that will take time, gumption and legislative assistance: “The impetus for laws is often the employers,” he said, “but more legislation is driven by pharmacies looking for reform.”  

While states work to address PBM reform (to the tune of about 350 bills currently under consideration), eliminating spread pricing and requiring a minimum reimbursement are common goals. They come with some downsides, Bryan said: “These state laws have a noble aim—to keep pharmacies open and get people prescriptions, but they’re going to make the plans more expensive for employers.”  

In drafting new PBM-directed legislation, states must pay close consideration to the preemptive power of the federal Employee Retirement Income Security Act of 1974 (ERISA), which can shield PBMs from state oversight to the extent services are provided to self-funded group health plans subject to ERISA. In 2020, the U.S. Supreme Court in Rutledge v. PCMA, provided state lawmakers a viable pathway for regulating PBM activity: state laws which merely seek to regulate cost and that do not govern a certain matter of plan administration will survive preemption. “In the wake of Rutledge,” noted Gross, “states like Indiana have sought to impose extremely comprehensive PBM laws.” While he remains hopeful these laws will eventually lead to long-term benefit employers – e.g., through price transparency pricing and by disallowing certain conflicts of interest, he believes employers will likely endure some short-term pain.  

Arkansas, Bryan said, may have found a way forward that’s worth emulating. Their recently passed reform law includes a “fair and reasonable” reimbursement requirement to pharmacies in large part to help protect independent pharmacies. Then again, that law already faces legal challenge from large chain pharmacies.

Each program wrapped with questions from the audience, the most common being about the future and potential of biosimilars.  

“Biosimilar prices are dropping rapidly,” Antypas said. “PBMs have made a lot of money in rebates from branded biosimilars, and you have to wonder why biosimilars are not preferred treatments. They have to be a priority.”  

PBMs without conflicts of interest have had preferred biosimilars for more than a year at this point, and this adoption has generated ample evidence that supports the safety and efficacy of biosimilars.  Both providers and patients are accepting biosimilars as first-line treatments, and with a dramatically lower price tag, there’s really no reason to cover the brand alternatives at all. 

Maybe the most telling moment came from a comment about “leaving the Big Three,” when a show of hands revealed that those employers who had found options outside those providers were more satisfied with their service than those who had not.  

While uncertainty reins, the impulse toward sticking with traditional choices may surprisingly not be the most stable and effective one.  

If our Bubbles + Benefits event series highlighted one thing, it’s that the regulatory and pharmaceutical landscape is increasingly complex. Navigating that complexity requires a trusted partner, one who brings innovative ideas, stays ahead of evolving changes, and understands the implications for employers like you. 

Interested in learning how we can help keep your future in focus during this time of uncertainty? Contact us today!