Health Plan Weekly

On June 28, the U.S. Supreme Court in two rulings eliminated a longstanding legal precedent that has protected regulations issued by federal agencies from a broad swath of legal challenges. Attorneys say rulemaking in health care will become more unpredictable as regulations are challenged — which could cost health plans, providers, and patients.

In their rulings in Relentless v. Department of Commerce and Loper Bright Enterprises v. Raimondo, the Supreme Court did away with “Chevron deference,” a legal concept that is over 40 years old. Chevron deference granted agencies the legal benefit of the doubt when they issued regulations that clarified parts of statute that Congress had left ambiguous. The premise behind the concept was that agency staff have subject matter expertise that Congress is unlikely to share, and that Congress couldn’t be expected to continually update statutes in order to address every emerging issue of importance to a specific sector of the economy.

A federal appeals court recently ruled that former Cigna Group executive Amy Bricker cannot join rival CVS Health Corp. due to a noncompete agreement, upholding a preliminary injunction from last year. While the case involving Bricker suggests companies can effectively prohibit employees from switching jobs, firms may no longer be able to do so later this year.

A Federal Trade Commission (FTC) final rule published in the Federal Register in May would ban most firms from enforcing or signing noncompetes with their workers. However, two attorneys tell AIS Health, a division of MMIT, the rule may not go into effect as planned on Sept. 4 due to multiple appeals. Indeed, in a July 3 ruling that put the ban on hold for groups seeking to overturn it, a federal judge wrote that the challenge is "likely to succeed on the merits."

While use cases for artificial intelligence are still largely being tested in health care, AI may be helpful right now for health plans seeking to manage their provider directories — a troublesome task that even the largest payers struggle to handle.

“There’s a lot of hype here, and really, so far, not much has really materialized,” said Neel Butala, M.D., cofounder of HiLabs, during a June 25 AHIP webinar.

“However, there’s a big appetite [for AI]…everything ranging from automating administrative tasks, apps, data analytics, to risk prediction, and even you know, personalized medicine. AI has applications in each of these buckets with varying ranges of maturity. And we feel, right now at least, that the easiest thing for people to engage AI in right now is automating administrative tasks. And this is because it improves efficiency; has direct, easily measurable ROI; and it’s pretty low risk for health plans in particular, as it's not really directly involved in member care. And finally, an easy win here can help any AI across an organization that can then be used…for other types of applications that are more advanced, that have a big impact.”

Although the Supreme Court has already weighed in on one case regarding states’ ability to regulate PBMs, the top law enforcement officials in more than 30 states are asking the high court to review another case that they claim will remove lingering uncertainty about the limits of states’ authority.

In PCMA v. Mulready, the current case, the Pharmaceutical Care Management Association is challenging an Oklahoma law — the Patient’s Right to Pharmacy Choice Act — which sets geography-based access standards for pharmacy networks. Among other provisions, it also bans PBMs from using discounts or cost-sharing differences to push plan members to certain in-network pharmacies, particularly those owned by that same PBM’s parent company.

The share of people without health insurance coverage reached an all-time low of 7.2% in 2023 but is projected to rise to 8.9% in 2034, according to the Congressional Budget Office.

The increase in the uninsured rate was largely due to the end of Medicaid’s continuous eligibility provisions in 2023 and 2024, the expiration of enhanced subsidies available through the Affordable Care Act (ACA) marketplaces after 2025 and a surge in immigration that began in 2022, observed the CBO in a report posted June 18.