redeterminations

The Affordable Care Act saves and is a prudent investment for America In my blog on Monday ( https://www.healthcarelabyrinth.com/what-will-happen-in-healthcare-with-gop-firmly-in-control/ ), I told you about the fact that a GOP Washington could mean a big change for healthcare policy. On one hand, I predicted that seismic changes may not occur for a number of reasons – 2026 election politics, Donald Trump’s desire to leave a legacy, and tight margins in each chamber of Congress. On the other hand, I said budget measures would be passed to extend tax cuts and that would have impact on healthcare and coverage. If seismic changes to healthcare occurred, the biggest worry would be what could happen to the Affordable Care Act (ACA). As I said Monday, Trump and his VP partner, JD Vance, sought to downplay talk of ACA repeal. But they did weigh in on possible changes during the campaign. GOP Speaker Mike Johnson

With the GOP likely in control of everything in D.C., what happens may come down to how aggressive Trump and Republican lawmakers want to be. While the weeks before the election certainly favored the election of Republican Donald Trump as president, the election outcome was in fact stunning. For the first time since George W. Bush in 2004, a Republican won the popular vote — by slightly less than 4 million votes and a majority of all voters. Leading up to the election, the electoral college looked like there were seven states that could swing either way – Nevada, Arizona, Georgia, North Carolina, Pennsylvania, Michigan, and Wisconsin. In the end, Trump beat Democrat Kamala Harris 312 to 226 in the electoral college, sweeping all seven of the battleground states. While many often saw Trump as hurting down-ticket candidates, he clearly had major political coattails this election. The GOP was always

Medicare Advantage’s additional value is driving savings in the traditional program I wrote about this Elevance Health study as part of my Healthcare Labyrinth Newsfeed but I was so excited about it I wanted to add to it in a blog. Capitol Hill is being dominated with headlines about gross overpayments to Medicare Advantage (MA). Estimates from various opponents, including congressional policy arm MedPAC and academics, put overpayments in the $80 billion range, with some now over $100 billion a year. As you know I dismiss these as fanciful. While some level of overpayment exists and needs to be reformed, some of the calculated overpayments are deliberate policy decisions by Congress and the fact that MA plans simply code better under the rules (even taking away the outliers and potential fraud). MA more efficient But often missed is that MA is far more efficient than the traditional and antiquated fee-for-service

Seismic healthcare changes unlikely regardless of election winners I love this time of year. I am a political junky through and through! The presidential and congressional elections are tomorrow in what is one of the closest races of modern times. While Trump appeared to be surging in the last week or so there is some evidence that the race again is tightening. The unknowns are: (1) how much has Harris’ closing message impacted undecided voters and (2) has historic undercounting of GOP support in the polls in many swing states continued or been solved. Here is where things stand right now. President Right now, odds show Trump ahead in most betting markets but Harris has closed the gap a little. The Real Clear Politics (RCP) betting averages is at about 58% for Trump, down from about 60% a few days ago. The popular vote is back to a tie in

Latest investigative report will increase focus on Medicare Advantage risk adjustment In a May 9th blog here ( https://www.healthcarelabyrinth.com/will-cms-rein-in-risk-adjustment-submissions/ ), I made the case that a reasonable reform to tackle Medicare Advantage (MA) overpayments may be to bar MA health plans from getting credit from diagnoses reported only via health risk assessments (HRAs) and other manual chart reviews.  After all, enrollees should be treated by a physician for any disease states or conditions and providers should know their patients well enough to report all diagnoses over time on encounter or claim submissions. At the time, there was a growing body of evidence about the impact of HRAs and manual chart reviews on MA plan payments — specifically, that many plans were reporting diagnoses only from HRAs and manual chart reviews and not on subsequent encounters from doctors. The Department of Health and Human Services’ Office of Inspector General (HHS OIG)

Striking major provision of qui tam lawsuits could hurt efforts to reduce fraud There is little doubt that fraud, waste, and abuse (FWA) is rampant in the American healthcare system. FWA ranges from gross inefficiency and poor use of healthcare resources all the way to outright illegal activity. In between there are all sorts of over-utilization and excessive testing. Outright fraud is up to 10% of our entire healthcare expenditures each year. FWA is likely up to 25%. With national healthcare expenditures expected to hit $5 trillion in 2024, up to $500 billion each year is fraud and $2.5 trillion is combined fraudulent, wasteful, or abusive spending. That is what makes the recent U.S. District Court of the Middle District of Florida decision on so-called qui tam lawsuits (I will call them qui tams from here on) very troubling. Federal Judge Kathryn Kimball Mizelle ruled last month that whistleblowers cannot file

A Trump victory would mean a sea change in healthcare policy The election is less than two weeks away. Given the huge sea change that could occur in healthcare policy, I thought it was time to devote a blog to my predictions on what might occur in the presidential, Senate and Houses races. I am a politics follower from way back. Early on in my career, I was a rightist youngster working for political action committees and political organizations. Later I was an editorial writer and political columnist prognosticating on state and local races. I also ran state legislative campaigns. As a governor’s appointee, I was smack in the middle of polls and political strategy. Predicting elections is a fool’s errand  What I learned through all of this is that predicting elections is very much a fool’s errand. It is never over until it is truly over and polls are

Big healthcare right now looks rocky and it could get worse Just a few years ago, investors were absolutely enthralled with big healthcare – the massive companies that led vertical integration and seemed to be delivering strong margins and robust outlooks. But today, the investment community is concerned about a number of high-profile missteps from these big companies as well as external pressures that may force change. The big healthcare companies So, what companies are we talking about? Of course, I focus in on the big companies that have insurers as a major piece of their business – this includes UnitedHealth Group, Elevance Health, The Cigna Group, CVS Health, Centene Corp., Humana, and Molina Healthcare. Most of these entities have either large, concentrated insurance lines or are combination insurers and service providers. Let’s take them one at a time and discuss some of their missteps of late. UnitedHealth Group (UHG)