Insurers and employers face rising costs from increased utilization, more expensive emergency care, higher mental health claims, and costly prescription drugs, particularly GLP-1 diabetes and obesity treatments. Enrollment dynamics are shifting as healthier individuals drop individual-market coverage, leaving a sicker, higher-claim population. Tighter eligibility verifications and fraud crackdowns make maintaining coverage harder for some. Potential reductions in federal support for marketplace subsidies could amplify premium pressures, especially in individual marketplaces. One-time high-cost gene therapies and other expensive drugs further strain budgets. As a result, premiums may rise and coverage may shrink, shifting more costs to patients.
Pricey prescriptions and nagging medical costs are swamping some insurers and employers now. Patients may start paying for it next year. Health insurance will grow more expensive in many corners of the market in 2026, and coverage may shrink. That could leave patients paying more for doctor visits and dealing with prescription coverage changes. Price increases could be especially stark in individual coverage marketplaces, where insurers also are predicting the federal government will end some support that helps people buy coverage.
In conference calls to discuss recent earnings reports, insurers ticked off a list of rising costs: More people are receiving care. Visits to expensive emergency rooms are rising, as are claims for mental health treatments. Insurers also say more healthy customers are dropping coverage in the individual market. That leaves a higher concentration of sicker patients who generate claims. Enrollment in the Affordable Care Act's insurance marketplaces swelled the past few years.
But a crackdown on fraud and a tightening of eligibility verifications that were loosened during the COVID-19 pandemic makes it harder for some to stay covered, Jefferies analyst David Windley noted. People who use little care "are disappearing," he said. Prescription drugs pose another challenge, especially popular and expensive diabetes and obesity treatments sometimes called GLP-1 drugs. Those include Ozempic, Mounjaro, Wegovy and Zepbound.
#health-insurance #premium-increases #prescription-drugs-glp-1 #individual-marketplaces #enrollment-and-eligibility
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