gopprimary

The fallout from the Clover Health Medicare Advantage (MA) Star Ratings decision has become considerably more complicated. What started as one health plan challenging its 2026 Star Rating has now developed into a series of lawsuits that could force the Centers for Medicare & Medicaid Services (CMS) to confront not one, but several competing approaches to calculating Star Ratings. And with Star Year (SY) 2027 ratings approaching, CMS may soon have to decide whether—and how—to extend any of those approaches across MA contracts. The important point is that the plans are not all asking for the same thing. That is where this story gets interesting and potentially very messy. I described this in an earlier blog as the Balkanization of Star measurement. Clover created the opening Clover filed its lawsuit in November 2025 after its largest MA contract received a 3.5 Star rating for 2026. On May 27, 2026, Judge

As usual in politics, the truth and best action is usually somewhere at the center There is a growing debate over the significant decline in Affordable Care Act (ACA) Exchange enrollment in 2026. The Trump administration and conservative policy organizations such as the Paragon Health Institute argue that much of the decline is good news: improper and fraudulent enrollees are finally being removed from the rolls. Others, including healthcare policy group KFF, point to a much different culprit — the expiration of the enhanced premium subsidies and the resulting affordability crisis. As I wrote recently in a Healthcare Labyrinth Newsfeed, I think the truth is somewhere in the middle. I am a strong supporter of affordable universal access to healthcare. It is one of the central tenets of my healthcare reform proposal. Premiums, deductibles, and other cost-sharing have to be reasonable if we expect people to maintain coverage, access healthcare,

A paradigm shift is looming in how CMS will oversee plans I have followed Medicare Advantage (MA) and Part D program audits for twenty years now. The evolution of the Centers for Medicare Medicaid Services’ (CMS) oversight has been amazing. The agency has moved from very lax standards and inconsistent enforcement to a carefully honed machine that has evolved standards (with Special Needs Plans (SNPs) protocols still evolving) and an exceeding level of professionalism. With that comes the annual program audit and enforcement reports. True, they have been published for years. But they have gone to the next level, with slick presentation emphasizing tips and best practices as to what plans need to know to drive performance on program audits. CMS’s latest Part C and Part D audit and enforcement report (from 2025 audits) sends a familiar — but increasingly important — message: compliance is no longer just about having

The industry, which was a financial basket case a short time ago, is cautiously recovering. The second quarter earnings season has ended and it largely confirms what many investors had been hoping for: health insurers seem to be turning the financial corner. As I point out in my recent The Healthcare Labyrinth Healthcare Reform Series (blogs and podcasts), macro trends are terrible, but at least the short-term signals show recovery and stability. Yet, reaction in the markets and even from battered health plan executives (who mostly and terribly missed the mark for several years) seems to be continued caution and for good reason. It is hard to put the whole industry in one box. Each is unique, driven by any number of factors: (1) the health plan lines of business they are concentrated in and (2) how big their so-called healthcare operations services entities are. But generally, most of the

The Trump administration’s elimination of the demonstration in an election year is a mystery. During an election year, it is hard to understand exactly why the Trump administration decided to end the standalone Part D (PDP) premium stabilization demonstration pilot in 2027. In fact, this has been a program I have been entirely critical of. The reason for the program itself goes back to the Inflation Reduction Act (IRA) of 2022, where Democrats did their usual conspiring to pass misguided, political provisions that essentially upend the financial underpinnings of Medicare Part D. In that bill, numerous changes were included that would lower or cap cost-sharing for a subset of Part D beneficiaries. The problem – it was largely unfunded and forced greater costs and risks on Part D plans. Medicare Advantage (MA) plans offering Part D found ways to limit the destruction, although the IRA changes did contribute to the

Affordability concerns will mean more uninsured and provider pains The Congressional Budget Office (CBO) recently released an updated projection on healthcare coverage and the news in the short and long term is not good. The uninsured rate could surge and undermine healthcare stability. In a July 23, 2026 publication on federal subsidies for health insurance, the CBO had a few interesting projections: The numbers show that costs will continue to surge and demand more and more government expenditures or tax deductions. Increases will result from growth in enrollment, prices, and service intensity. For example, subsidies for Medicare are projected to nearly double over the next decade, increasing by about $900 billion, or 86%. From 2026 to 2036, total federal subsidies are projected to increase by about 1 percentage point as a percentage of GDP. Much of the enrollment losses can be tied to the changes in the One Big Beautiful Bill Act

July enrollment shows MA continues to grow, with SNPs a majority of the increase In a February 16 blog, I detailed the growth in Medicare Advantage (MA) from February 2025 to February 2026 after a delay from the Centers for Medicare and Medicaid Services (CMS) in posting the annual data. As I noted, the January enrollment statistics in both years seemed off so many analysts are comparing February to February each year. Each month since then I have updated with monthly growth numbers. Now, we have July results. For those who may have missed earlier blogs, I am refreshing on some of the annual results. The annual statistics show some of the financial struggles the industry continues to have. Annual growth is way down compared with prior years in the 2020s due to major geographic contractions as well as plan benefit reductions by major MA players the past few years.

The time has come for a real fix to Medicare physician fees. The big stall is hurting healthcare. Poor Medicare docs. They have been on a proverbial reimbursement roller coaster for decades now. They are literally the ugly stepchildren of Medicare fee-for-service (FFS) providers. Hospitals, other facilities, and other provider groups get more attention, with hospitals dominating the money. The ups and downs have undermined independent practices, led to our primary care deficit, and actually fostered physician group acquisitions that increase costs in the healthcare system in several ways. More background The long and short of it is that Medicare physicians have had a rather broken rate system dating back to 1992. The bad system has been undermined further with various budget reduction requirements applied to the physician rates along the way. Congress created the Medicare physician fee schedule through the Omnibus Budget Reconciliation Act of 1989. At the time,

My seventh Clover blog updates on the Elevance Health lawsuit (the first that was filed). The lawsuit Elevance Health filed on July 1 on its Medicare Advantage (MA) Star Year (SY) 2026 Ratings is moving along. While a great deal remains unknown, the Elevance case could help us understand the timing of and conditions of any further changes in SY 2026 and what might be done in SY 2027. Elevance filed on July 1, while Scan did so about a week later and Alignment about 10 days later. Note my use of the words “could” and “might” as a great deal remains unknown. Here is a quick update on the Elevance Health lawsuit since the complaint was filed. In its July 1 Complaint, Elevance Health argued the Centers for Medicare and Medicaid Services (CMS) acted arbitrarily and capriciously in calculating Clover Health’s Star rating change based on the judge’s “Clover

Conservative think tank has important points for the future of healthcare In the past few weeks, I have had both a blog series and podcast series on healthcare reform. Now out comes a detailed report by the influential and conservative Paragon Health Institute calling for major healthcare reforms. These include federal funding cuts or reductions in tax allowances impacting all health plan lines of business as well as cuts to providers and programs more broadly. As I have said before, people should pay attention to what Paragon is saying. The institute’s president was in Trump 45. Many Paragon staffers are in Trump 47. Paragon fellows hold or have held key positions in Trump 47. People pay attention to what Paragon says given its impact on the One Big Beautiful Bill Act (OBBBA). It, too, has influenced various regulatory proposals from the Trump administration, especially regarding improper enrollments and fraud in