entitlementreform

A busy year in healthcare with insurer woes, a new president, and a decidedly different healthcare policy approach. As is my tradition at year’s end, I reflect back on all that occurred in healthcare in the year. It was a big year in healthcare and the new administration portends another massive one next year. I will have my 2026 healthcare predictions blog later this week. So, here are the major healthcare happenings from 2025. You can go to various blogs at the blog tab of this website to learn more. Presidential transition The year began with a presidential transition, with Joe Biden exiting the White House and Donald Trump returning after four years in the political wilderness. Trump has taken a decidedly different approach to healthcare coverage, but at the same time has shocked some with efforts to reduce drug pricing and coercing definitive concessions from Big Pharma. Trump convinced

An incredible analysis from Wakely Consulting, one of the foremost actuarial firms in the Medicare world. Wakey finds that annual wellness visits (AWVs) can demonstrably help control costs among Medicare beneficiaries. As the firm notes, AWVs are meant to identify disease states and conditions as well as create a care plan to act as a long-term preventive action plan. Wakely looked at a sample of traditional fee-for-service (FFS) Medicare program claims from 2018 – 2023. Beneficiaries who met the criteria for the institutional, end-stage renal disease (ESRD), or new enrollee risk score models were excluded. As well, only Medicare beneficiaries in the community with full calendar year data were included. The final sample comprised 733,532 beneficiaries with data for each year. Wakley also took into consideration social determinant and disease state impacts. Wakely broke out the sample into the following: Wakley found that AWVs are considerably underutilized. About 45% of

Given the holidays, we are going to be brief this week. Just a few ruminations from me today about recent healthcare events. We will do a quick blog on Friday regarding a great analysis by Wakely Consulting regarding the importance of wellness visits and prevention in Medicare. Next week, we will have my 2025 Healthcare Year in Review on Monday (12/29) and my Healthcare Predictions for the 2026 Year Ahead on that Friday (1/2). Here is wishing everyone a Merry Christmas, Happy Hanukkah (today is the last day), and Happy New Year. The courage of the moderates I have to give great credit to four GOP House moderates who have signed on to a Democratic discharge petition to force a vote in the House on extending the enhanced Exchange premium subsidies. They did so only after House Seaker Mike Johnson, R-LA, broke his promise to allow an amendment vote on

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) in December 2025. The results show some interesting trends as we go into 2026. Many have predicted that MA enrollment could contract in 2026. I have said on a number of occasions that I doubted we would see that and instead see enrollment that is relatively flat or extremely small in terms of growth. I surmised that while most national plans want to see their enrollment contract by millions, I suspect regional plans will take on the challenge of enrolling robustly despite some financial risks. While it is too early to tell what will happen, we can read some tea leaves in the December data. What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025 because of issues with the January 2025 statistics.) Enrollment in

Each year during open enrollment I get calls from family, friends, and even referrals from outsiders to help solve some of their perplexing insurance woes. I have tried to limit my so-called portfolio of free clients, but the caseload continues to be robust given the crushing affordability crisis. Here are a few of the cases I supported this year. At the end, I wil sum up and give you a feel for what changes need to be made to ensure all Americans gain affordable healthcare. 30-year-old graduate student with no employer sponsored coverage – good outcome individually but shows the huge inequity of the coverage gap as well as rising unaffordability This person was on an Exchange Platinum plan in 2025 because of previous complex surgery and required follow-ups. As a student, the person was unsubsidized in the Exchanges for years because Florida did not expand Medicaid. No Exchange subsidies

MA in store for a challenging year There have been significant developments on the Medicare Advantage (MA) front of late. Here is a recap of some big developments going into the new year. 2026 program audit protocols  On November 20, the Centers for Medicare and Medicaid Services (CMS) issued its annual program audit memo to describe changes. While in the past few years little changed, there were some major developments this year. Let’s briefly describe them: CMS will continue using the existing 2025 Final Audit Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) to conduct 2026 program audits. But CMS did announce a great many process changes: CMS also updated on the 2026 schedule: MA changes going into 2026 MA is contracting again, but there are some interesting trends. Star performance and changes When Star Year (SY) 2026 ratings

Crushing costs may mean a relook at comprehensive coverage Zeke Emmanuel, one of the key authors of the Affordable Care Act (ACA), had an interesting opinion piece in The Washington Post on December 2. He articulates many of the same things I say in my book, The Healthcare Labyrinth, and offers a blueprint in part for lasting reforms. A key one is price reform – one of my three tenets of healthcare reform (which also include comprehensive coverage and primary care and care management). On price, Emmanuel notes that hospital prices have risen faster than any other sector since 2000. I have made the case that hospitals are entirely unaccountable, and they control more than just emergency rooms, outpatient, and inpatient care. They have taken over at least half of physicians in the country and have gutted independent primary care and changed practice patterns to encourage use of high-cost hospital-owned

On November 25, the Centers for Medicare and Medicaid Services (CMS) issued its proposed Medicare Advantage and Part D rule for Calendar Year 2027. Despite the government shutdown, the proposed rule was issued on time – even a few days early. The rule is expected to be finalized in late March or early April after a comment period that ends in late January. The rule is accompanied by some major Requests for Information (RFIs) as well. Star Ratings proposed changes I went into details about the Star Ratings proposed changes in a November 28 blog. You can get all the details here: https://www.healthcarelabyrinth.com/cms-medicare-advantage-star-program-to-get-tougher/ . Here is a quick summary though of major Star changes proposed: In Measure Years 2026 and 2027 (Star Years 2028 and 2029), CMS proposes to remove 12 measures focused on operational/administrative processes or those that no longer show variability in quality among plans. That has the

While many plans will not cry about the elimination of the Excellent Health Outcomes for All (EHO4all, the former Health Equity Index (HEI)) reward from Medicare Advantage Star Ratings, some plans have invested heavily to make the conversion to the new health equity improvement program. And the big question is whether the Trump administration is violating due process and the Administrative Procedure Act (APA) by eliminating the new reward as of SY 2027 with almost no notice. Here is some of my thinking on this: Some plans could challenge the provision and that would be legitimate. The HEI proposal went through full rulemaking back in 2023. Plans had sufficient notice to plan for the major change. They do not now. They relied on the sunset of the Reward Factor and conversion to the EHO4all Reward in their business decision-making. Federal courts recently cited adequate notice provisions under the APA to

NOTE: This blog is co-published with Lilac Software. See the end of the blog for more information on Lilac’s Stars platform and agentic AI solutions. The skinny on Star changes in the future and how tough it may be, especially for Special Needs Plans. On November 13, I did a blog (see it here: https://www.healthcarelabyrinth.com/cms-likely-to-remake-star-ratings/ ) that said the Centers for Medicare and Medicaid Services (CMS) plans on remaking the Medicare Advantage (MA) Stars program by eliminating easy-to-hit operational measures and replacing them with tougher clinical measures. Sure enough, CMS acted on this on November 25, publishing a draft MA and Part D rule for 2027 that would make sweeping Star changes. Major measure realignment Beginning primarily in Measure Year (MY) 2027 or Star Year (SY) 2029, CMS proposes to remove 12 (really 14 based on duplication in Parts C and D) measures, largely focused on operational/administrative processes or those