Rodger Bayne, president of Benefit Indemnity Corp. in Towson, Maryland, puts it more bluntly. "The U.S. health care system is perilously close to failure," he says. "Clearly, lifesaving technology needs to be embraced, but the costs we are seeing for such new technologies are cost-prohibitive to the extent that they continue to push the system to the brink of failure."

Chris Bell of Chris Bell Insurance in Lee's Summit, Missouri, sees both positives and negatives in the current landscape.

"Medical coverage for pre-existing conditions is great, because many people would not be able to pass underwriting if there were not options available to them," he says. "However, the cost of prescription drugs is very high for name brands. This leads to some not being able to afford the medicine that can best help them, even with insurance coverage. My concern is that many Part D drug companies are increasing the cost of tier-three medicines this year to a percentage that will make the medicine much more expensive than when it was at a copay."

Whether the U.S. system is on its deathbed or merely sick, industry leaders agree that reform is long overdue. They are keeping an eye on several issues in the fourth quarter of 2023 and heading into the election year. As always, cost is at the top of the list for employers and benefits advisors.

"Employers are anticipating another 7% increase in health care costs for 2024," says Julie Stich, vice president of content for the International Foundation of Employee Benefit Plans. "Plan sponsors have indicated that chronic health conditions have a considerable effect on their medical expenses. That ties to the data that disease management and wellness programs rank high in cost-management strategies."

It remains to be seen how attempts to rein in Medicare prices will play out. The Centers for Medicare & Medicaid Services in late August announced the much anticipated list of the first 10 drugs selected for Medicare price negotiation under the Inflation Reduction Act.

"The government negotiating with drug companies will help lower the cost of medicines, but we are always worried about unintended side effects," Bell says. "If the drug companies raise the price for the consumer because their reimbursement rate was cut, they will most likely pass an increase to the consumer."

Several manufacturers have said the new provisions are unconstitutional and filed a series of lawsuits to try to stop them. The Pharmaceutical Research and Manufacturers of America says the policy gives the government too much power and would hurt the innovation and investment needed for the Biden administration's push to end cancer. "This is going to be a heavyweight battle," says Ameet Sarpatwari, an assistant professor at Harvard Medical School.

In another cost-containment area, Roberts expects to see greater use of the Affordable Care Act's family glitch fix during open enrollment this fall.

"The fix was introduced in the middle of last year's enrollment season for 2023 plans, but it was confusing, many people were unaware of it, and it was likely underutilized," he says. "Now that the industry and consumers are more familiar with the fix, I hope to see more people use it when enrolling in 2024 plans. Per Kaiser Family Foundation, an estimated 5.1 million people were ineligible for exchange and Marketplace subsidies because of the former family glitch."

Although medical advances hold great promise for patients, they also exacerbate price uncertainty. Wegovy, a new obesity drug from Novo Nordisk, reduced the risk of serious heart problems by 20% in a large clinical trial. Although the trial results demonstrate that obesity drugs may have significant health benefits beyond shedding unwanted pounds, organizations representing U.S. insurers emphasized that the data is still preliminary. They also expressed concern about the high costs involved with covering those medications, which are nearly $1,350 per month for a single patient.

"It's impossible to evaluate the efficacy and long-term effectiveness of a prescription drug based solely on a drug manufacturer's press release," says David Allen, a spokesperson for America's Health Insurance Plans. "Health insurance providers will continue to analyze new evidence as it becomes available."

Along with price, access to health care remains a major concern. Last spring, a federal judge in Texas ruled that the federal government cannot require ACA-compliant plans to cover preventive services recommended by the U.S. Preventive Service Task Force at no cost.

"This effectively eliminated coverage for all preventive care items recommended by the USPSTF beginning the day the ACA was signed, after having covered them previously since its inception," Roberts says. "This eliminates zero-cost coverage for items such as colorectal cancer and lung screenings, medications to prevent heart disease, perinatal depression prevention, HIV and STI screenings, and anti-HIV medication pre-exposure prophylaxis."

Access to abortion is also a mixed bag in the wake of the Dobbs decision, with constitutional amendments on the ballot in several states this fall. "I would like to see national clarity on access to abortion and on rules regarding outside state travel for abortion access," he says.

Bell has two items atop his health care reform wish list. "Most restrictions on preauthorization delay or prevent people from getting the care they need," he says. "Also, the insurance companies' coverage of skilled nursing care needs to be updated, because many people need more days in skilled nursing care that they are not getting."

As an added wrinkle, health care reform will play out against the backdrop of presidential, congressional and state elections next year. "I doubt that health care will be an important issue in this presidential election, because there are too many distractions," Bayne says.

Roberts, however, believes the abortion issue could move health care to the front burner.

"As we have seen in recent state voting outcomes, most recently in Ohio, Americans seem to be fervently passionate about access to abortion— especially millennials and Gen Z," he says. "While I think the topic will be important during primaries, I think it will be in the brightest spotlight during the presidential election."

Although not everyone agrees on the problems facing the health care system, let alone the solutions, they do agree that remaining educated and involved is essential.

Read more: Employers expect a 7% hike in health care costs in 2024

"I encourage people to stay engaged, informed and attentive to these issues, as well as other movement in the industry," Roberts says. "They should discuss things with clients, colleagues and community. Insurance professionals are valuable, because they have information that the average person does not. People need access to insurance, and they rely on their advisors and other professionals to guide them through an industry that they do not know how to navigate."

Bell agrees. "I would encourage clients to make sure they are working with an advisor who knows the plans that are available in their area," he says. "The advisor will know which plans are easier to work with and can help to explain what changes are taking place from year to year that impact the beneficiary."

Bayne believes benefits advisors can add value by helping clients navigate the confusing world of health care reform. "Failure to continue to study our craft can lead to stagnant representation of our most precious clients," he says. "Success in our business comes from applied knowledge."