Looking back at 2025: Health shifts that matter for insurance professionals
2025 reshaped cost curves and risk pools. GLP-1 drugs scaled, vaccine guidance changed, coverage churn accelerated, and AI moved from buzzword to real operational value. Here's what mattered and how to act on it.
GLP-1 drugs went mainstream - and cheaper deals may follow
GLP-1 medications like Ozempic, Wegovy, and Zepbound saw a surge in uptake as access improved. Federal deals with major drug makers were announced in the fall, signaling potential price relief.
For carriers and self-funded plans, this is a double-edged sword: higher utilization and pharmacy spend now, but potential downstream savings if metabolic health improves. Update formularies, outcomes tracking, and prior auth criteria to focus on adherence, comorbidity reduction, and total cost of care - not just unit price.
Food policy took aim at "Big Food" and ultra-processed ingredients
Health officials raised alarms on ultra-processed foods and moved to restrict certain food dyes. If sustained, this prevention-first posture could shift long-term morbidity trends tied to obesity and cardiometabolic disease.
Near term, expect more member interest in nutrition programs and GLP-1 coverage. Consider layering digital nutrition support and coaching into care management for high-risk metabolic cohorts.
Vaccination guidance shifted amid rising skepticism
Federal guidance removed COVID vaccination for healthy children and healthy pregnant women from the CDC's schedule. Independent groups, including the American Medical Association and the American Academy of Pediatrics, continued to recommend COVID boosters for these populations. The CDC's advisory committee also moved to limit routine newborn hepatitis B vaccination to babies considered high risk.
Insurer takeaway: uneven vaccination rates increase outbreak risk and acute care costs. Track regional immunization gaps and align care management, communications, and provider outreach to reduce avoidable admissions. For context on pediatric immunization stances, see the American Academy of Pediatrics.
Coverage churn accelerated: Medicaid changes and subsidy expirations
Work requirements and tighter eligibility are expected to push millions off Medicaid. Enhanced marketplace subsidies are set to expire at the end of 2025, which could push healthier members out and skew pools older and sicker.
Expect higher lapse rates, adverse selection, and premium pressure. Strengthen retention campaigns, refine risk adjustment strategies, and coordinate with brokers on rapid reenrollment paths. For ongoing analysis of coverage shifts, the Commonwealth Fund remains a useful resource.
AI delivered real gains in care and operations
AI advanced diagnostics and early detection, and it helped stabilize some operational costs. For insurers, the opportunity sits in smarter prior auth, claim triage, SIU flagging, network optimization, and member outreach.
Move fast, but keep your audit trails, model governance, and PHI safeguards tight. If you're upskilling teams, see practical programs by role at Complete AI Training.
Action checklist for insurers and TPAs
- Pharmacy: Update GLP-1 criteria, negotiate outcomes-based contracts, and track clinical markers (A1c, BMI, comorbidities) tied to total cost reductions.
- Benefits design: Pair GLP-1 coverage with nutrition and behavior programs to improve persistence and ROI.
- Underwriting and pricing: Model post-subsidy exchange risk drift and Medicaid churn; stress-test for adverse selection.
- Network and care management: Target regions with low vaccination rates; prepare outbreak response pathways with pediatric and OB networks.
- Compliance and comms: Clarify vaccine coverage policies to members and providers; reduce confusion from conflicting guidance.
- AI strategy: Deploy pilots in prior auth, claims routing, and SIU; measure cycle-time cuts and loss leakage; maintain explainability.
- Data: Stand up dashboards for GLP-1 utilization, discontinuation, and weight rebound risk; monitor inpatient trends for measles and other VPDs.
- Retention: Proactive outreach to subsidy-exposed members with lower-cost plan options and broker support.
What to watch in early 2026
- Final details and timelines on federal drug pricing agreements affecting GLP-1s.
- Exchange enrollment impacts as subsidies sunset; premium filings and rate justifications.
- Measles and other outbreak trends in under-immunized counties; hospital capacity signals.
- AI oversight expectations from regulators and required documentation for audit readiness.
Bottom line: 2025 pushed pharmacy costs up but opened a door to long-term metabolic savings, stirred vaccine-related risk, and set the stage for coverage volatility. Teams that price carefully, communicate clearly, and operationalize AI with discipline will defend margins while improving member outcomes.
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