medicaid

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

A quick blog to tell you about enrollment growth in Medicare Advantage (MA) in both October and November 2025. The October data was delayed due to the government shutdown. Recently, both the October and November data were posted. Due to the financial meltdown of health insurers in general and in the MA line specifically, many of the biggest plans have sought to restrain growth. But growth has continued throughout the year because of some strong benefit packages still out there and the better value in MA compared with traditional fee-for-service (FFS) Medicare. We are now in open enrollment for 2026 so we will continue to see growth in Q4 2025 because of some enrollees who are able to switch early (before January 2026) with special enrollment periods.   What do the latest statistics show? Growth from January 2024 to February 2025 was 4.39% or 1.468 million. (I used February 2025

Weight-loss drug concessions are positive, but not seminal reform. The Trump administration announced yet another major development on the drug pricing front. In an October 9 blog, I told you about a set of initial drug price concessions President Donald Trump got from a few Big Pharma companies. On November 3, I discussed a related topic on the drug front – Cigna’s pharmacy benefits manager, Express Scripts, announcing a slow migration away from gross and rebate pricing to a net basis. You can go to the blog tab and those dates to read more. Now, Trump announced drug price concession deals with two GLP-1 weight-loss brand drug makers – American firm Eli Lilly and Danish firm Novo Nordisk. What are GLP-1s? The two leading types of GLP-1 weight-loss drugs are semaglutide (sold by Novo Nordisk as either Ozempic or Wegovy) and tirzepatide (sold by Eli Lilly as either Mounjaro or

Annual announcement updating Medicare beneficary payments reminds us how antiquated Medicare fee-for-service (FFS) really is. It is on life support. The Centers for Medicare and Medicaid Services (CMS) released its annual updates for traditional Medicare Part A and B premiums deductibles, and cost-sharing. There was a huge surge in Part B premiums monthly by 10%. The Social Security cost-of-living increase was just 2.8% or about $56 per month on average. The Part B premium increase will eat up $18 of that. When this comes out, I reflect on a few things. How antiquated traditional Medicare fee-for-service (FFS) really is. It is stuck back in the 1950s/1960s and the 80-20 indemnity world. While CMS champions how many providers are now in a value-based reimbursement program, there is nothing stunning there — true savings (if any) is a rounding error in the $1 trillion plus behemoth. Traditional Medicare is on life support.

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. As low as Stars are right now, reaching higher in the future could be tougher A bit of a bombshell from Health Payer Specialist (link at the end of the blog) — well, yes and no. Officials at the Centers for Medicare and Medicaid Services (CMS) told the publication that changes likely are coming to the Medicare Advantage (MA) and Part D Star rating program. And this could make Star achievement even more difficult in a current environment where ratings are already in the doldrums. As I have said in the past, CMS and the White House have prominent conservative policy advisors, including from Brian Blase’s Paragon Health Institute. The think tank holds great sway in both the Trump administration and Congress. I have noted

UnitedHealthcare study may mean Congress takes up vertical integration reform A recent study published by Health Affairs about what UnitedHealthcare pays its sister providers compared with other network providers could ignite renewed scrutiny of vertical integration. It could also lead to a fresh look at what some call the gaming of the minimum medical loss ratio (MLR) mandate that touches virtually all insurance product types out there except self-insured employer coverage. The study finds that UnitedHealthcare pays its owned providers at sister company Optum 17% more than those it does not own. And if United controls 25% or more of a market, that percentage increases to 61%. Again, researchers said the results suggest the company may be sidestepping government rules regarding calculation of medical expenses against premiums. If those rules are not met, rebates need to be sent to the government, employers, or individuals depending on the type of coverage.

Huge utilization and medical expense still a factor in insurer recovery Given the fiscal crisis happening in the health plan industry, I thought a quick blog summarizing Q3 2025 financial reports made sense. As well, a few more updates on Medicare Advantage (MA) contraction. One of my biggest observations is that medical loss ratios (MLRs), the way health plans measure the percentage of medical costs against premiums, remains at record levels. This appears to be across all lines of business – government programs and commercial/employer coverage. When MLRs are at 90 or well into the 90s (with the exception of commercial-only Cigna), you know things are upside down financially. And while plans continue to recover financially, there is little sign that high utilization, inflation, and costs will temper anytime soon. Further, developments in Medicaid and Exchanges as well as to some degree in MA could further complicate the medical cost