Open Enrollment Blues
November 18, 2025
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Hello and welcome back to TrustWorks On Call, here with your healthcare business and strategy 411 for the week. If you enjoy our work, please consider forwarding it along to a friend and encouraging them to subscribe!
One programming note, we’ll be off celebrating Thanksgiving next week, meaning you’ll have to wait until Tuesday December 2 for your next TrustWorks On Call. In the meantime, we are wishing for all our readers to have a restful, grateful, and delicious Thanksgiving break. We are thankful as always for your readership.
This week, we’ve got double coverage on health insurance. First, we go Beyond the Whiteboard with a graphic the growth of employer health plan costs, then we’re Dialing In on the expansion of catastrophic coverage in the ACA market. But first, the news:
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Behind the Headlines
Unpacking the forces driving healthcare's biggest stories.
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1. Telehealth flexibilities briefly extended as government reopens.
- As part of last week’s “minibus” bill to end the government shutdown, Congress extended Medicare telehealth flexibilities and hospital-at-home waivers, which had lapsed for the 43-day shutdown, until January 30, 2026.
- The Drug Enforcement Agency (DEA) also published a notice last week that flexibilities allowing the teleprescription of controlled substances will be extended for a fourth time, which is expected to last through the end of 2027.
- An $8B cut to Medicaid Disproportionate Share Hospitals (DSH), scheduled by the Affordable Care Act (ACA) and continuously delayed since 2014, briefly took effect during the shutdown, but Congress has again delayed these cuts until the end of the current continuing resolution on January 30, 2026.
TrustWorks Take: The deal to reopen the government kicked the can down the road for several healthcare policy items, but not very far. Providers' collective exhale of relief over the reinstatement of Medicare telehealth flexibilities, hospital-at-home waivers, and averted DSH cuts will be immediately followed by another round of collective breath-holding as the same provisions hang in the balance during funding negotiations this January. The DEA managed to extend teleprescriptions of controlled substances without a lapse, but the Trump administration has not made public progress on a permanent framework since it rescinded a proposed rule issued by the outgoing Biden administration.
These repeated, short-term extensions are bad policy because they inhibit large-scale, long-term investments from provider organizations, which are necessary for initiatives like hospital-at-home programs to reach full scale. The Medicare telehealth flexibilities enjoy bipartisan support, negligible fiscal impacts, and widespread industry backing, specifically for an extension of at least five years. However, as long as Congress keeps legislating against the funding clock, we’re likely to keep getting short-term thinking instead of long-term extensions. |
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2. Indiana approves COPA hospital merger against FTC wishes.
- Last week, Indiana Governor Mike Braun announced that the state health department had approved Union Hospital’s acquisition of Terre Haute Regional Hospital from HCA Healthcare under the state’s first-ever Certificate of Public Advantage (COPA), which bypasses federal antitrust regulation in exchange for stronger state oversight.
- Union Health lobbied Indiana to pass its COPA law in 2021, specifically so that it could acquire Terre Haute Regional, for which it submitted an application in 2023, before pulling that application amid pushback from federal regulators.
- Union Health’s resubmitted application in 2025 was still opposed by the Federal Trade Commission (FTC) and Indiana’s attorney general, but the Indiana Department of Health found that the benefits of the merger outweighed the harms, which include creating a “monopoly for inpatient acute care services in Vigo County.”
TrustWorks Take: COPAs are premised on the idea that regulation can replace competition as the primary constraint keeping hospital prices low and quality high. Although this could be true in theory, hospital mergers that used COPAs have posted a bad track record, according to FTC research. For example, the 1995 COPA that created Mission Health in North Carolina from two competitor hospitals included margin and cost controls, but the system was still found to have increased its commercial inpatient prices by over 20 percent more than its peers during its first decade under the COPA. Then, after Mission Health lobbied North Carolina to repeal its COPA, its prices increased by another 38 percent. Not only are COPA regulations often ineffective at controlling price growth, but also when COPAs expire (as is the case in Indiana), they leave behind an unregulated monopoly.
Despite some disappointing results, state governments keep turning to COPAs because they are an imperfect answer to an important question: how can we support and sustain struggling hospitals? Other research has found that “COPA regulation, if properly designed, can effectively constrain prices in the absence of competition among providers.” The problems arise because it is very difficult for state governments to design a regulatory scheme that prevents evasion while being flexible enough to allow for industry changes over the full COPA duration. Still, for many state legislators, the logic is that it’s better to try a regulated monopoly, with price increases perhaps higher than ideal, than risk an inpatient care desert due to a hospital closure.
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3. Researchers find answer to pig-kidney transplant rejections.
- A team of researchers at NYU Langone Health identified and reversed a set of immune reactions that drive the human body’s rejection of genetically modified kidneys grown in pigs for human use, a process known as xenotransplantation.
- By mapping the immune activity around the transplant, the researchers identified that organ rejection was driven by antibodies and T cells that could be tempered with Food and Drug Administration-approved drugs.
- Their report, published last week in Nature, was based on monitoring the transplantation of a genetically engineered porcine kidney into a brain-dead recipient, with a beating heart and on a ventilator, for 61 days after surgery.
TrustWorks Take: At this year’s International Xenotransplantation Association conference held last month, scientists celebrated the success of the first two patients to live with porcine-grown kidneys for at least six months (one of which has since been removed), as well as the launch of clinical trials for xenotransplantation in the US and other countries. The field still faces challenges around minimizing rejections by moderating immune response, which this breakthrough by the NYU Langone researchers helps address, and preventing crossover events of zoonotic diseases, but we’ve reached a turning point now that xenotransplantation is happening successfully.
The stakes behind finding a scalable source for kidney donations are massive. In the US, nearly 555K Americans are on dialysis, and about 90K people are registered on the kidney transplant waiting list, but less than 30K kidney transplants are performed each year. The widespread availability of effective and safe porcine kidney transplants could extend the lives of the thousands of people each year who die waiting for kidney transplants, while also generating significant savings for our healthcare system.Almost one in four dollars Medicare spends goes to treating kidney disease. Spending on dialysis for end-stage renal disease occupies seven percent of Medicare’s budget, despite caring for only one percent of its beneficiaries.
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Beyond the Whiteboard
Visualizing key trends from the healthcare industry
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Commercial Insurance Premium Increases Feel Unsustainable
Every fall, KFF publishes perhaps the authoritative account of commercial group-coverage price growth with its Employer Health Benefits Survey. Its lookback on 2025 found that family premiums grew by over 6 percent this year, with employers contributing over $20K to annual family premiums, which now total nearly $27K. That equates to an astounding 32 percent of median household income.
It didn’t use to be like this. Since 2010, employer premium contributions have more than doubled and worker contributions have increased 71 percent, whereas the Consumer Price Index has only risen 48 percent and household income just 22 percent in that time. The result of health insurance costs outpacing inflation growth for so many years is the suppression of profit margins for businesses and wages for workers, putting American firms at a competitive disadvantage to companies abroad. Americans say that “costs” are the most urgent health problem facing this country, so it’s no coincidence that opinions on the state of US healthcare coverage are at a fifteen-year low. With each successive year, we ask the question with new urgency, when will employers reach their breaking point?
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Dialing In
Sharing insights from our work with clients
The Catastrophic Coverage Conundrum
Healthcare is one of those industries where you can’t always avoid taking your work home with you. My family (that is myself, my wife, and our son) recently got our 2026 ACA exchange renewal notice here in Virginia. The same UnitedHealthcare family plan that cost $2,393 per month in 2025 is jumping to $3,310 per month, a 38% increase. We’ve been seriously considering self-insuring and pairing it with a catastrophic-only policy. And as it turns out, the Trump administration was one step ahead of us, having announced in September that it’s now much easier to qualify for a hardship exemption to purchase a catastrophic-coverage ACA plan, which used to be heavily restricted for those 30 and older.
This expansion of catastrophic coverage at a time when healthcare has never been less affordable may seem a little cruel, but it’s also a natural endpoint of trendline we’re on. In 2024, even as the US uninsured rate was near its all-time low, almost one quarter of working-age adults were considered "underinsured,” due to their out-of-pocket cost exposure. As people shift toward lower-premium, higher-deductible plans in response to rising plan prices, we’re encouraging the idea that health insurance is to be had but not used, except in emergencies. Without the ACA subsidies’ premium support, this problem will only intensify, triggering yet another vicious cycle. The problem is that premiums are what make insurance work: everyone pays into a pool, so that those who need help get covered by those who don’t. Instead, we’re losing the point of insurance to the size of the deductible, which the deregulation of catastrophic coverage will only exacerbate. The two groups of people selecting catastrophic coverage this fall will be people of means who can afford to self-insure and those who can’t afford anything but catastrophic coverage, when in a more just system the former would be subsidizing the latter.
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