redeterminations

Trump did not salvage the Affordable Care Act — he sabotaged it. Tall tales are always part of politics and candidate debates. America takes it for granted. But the biggest lie of the vice-presidential debate Tuesday night was quite the doozy and I could not let it go without some explanation. The big lie can be credited to GOP vice presidential candidate JD Vance. Vance attempted to concoct a story that somehow former President Trump salvaged the Affordable Care Act (ACA) when it was on the verge of collapse. This of course is true only in Vance’s and Trump’s minds. Vance’s fanciful rewrite of history went like this. Vance said Trump “actually implemented some of these regulations when he was president of the United States. … And I think you can make a really good argument that it salvaged Obamacare, which was doing disastrously until Donald Trump came along. I

I promised to follow up on my newsfeed on The Wall Street Journal’s (WSJ) editorial on the Federal Trade Commission’s (FTC) lawsuit against the Big 3 pharmacy benefits managers (PBMs) – CVS Caremark, Cigna’s Express Scripts, and United’s OptumRx. I feel so much is wrong with what the WSJ editorial board is saying about the lawsuit. So here are some additional thoughts on the subject. The editorial is at a link below so you can read as well. What does the lawsuit charge? The FTC’s bombshell lawsuit charges that the PBMs have used formulary placement and rebates to rig the system and disadvantage the American public at the point of sale. While the FTC believes the anticompetitive activities permeate the entire system and apply to almost all brand drugs, it is focused in this lawsuit on insulin prices. The FTC says that the PBMs use the formulary and rebate scheme to

The Federal Trade Commission (FTC) unveiled a bombshell lawsuit last week against the Big 3 pharmacy benefits managers (PBMs) – CVS’ Caremark, Cigna’s Express Scripts, and United’s OptumRx. The FTC charges that the PBMs have used formulary placement and rebates to rig the system for themselves and disadvantage the American public. The FTC says that the PBMs use formularies and rebates to line their pockets and to attract business. This leaves those with expensive disease states, such as diabetics dependent on insulin, with high prices and often an inability to pay. While the FTC believes the behavior by the PBMs impact many drugs and disease states, the lawsuit focuses on insulin drugs and prices right now.  In the past, I have defended PBMs for some of the good they do. They do promote the use of generics and keep down overall costs with prior authorization (PA) and other utilization management

Every three years, The Commonwealth Fund does a great public service by publishing its “Mirror Mirror” analysis of developed world healthcare systems. This is the eighth report, which relies on surveys as well as national and international healthcare data. The 2024 analysis accounts for the COVID pandemic impacts and results are consistent with previous years.  In effect, the Commonwealth Fund ranks healthcare systems’ performance based on leading access, efficiency, quality, and value metrics. It looks at 70 health system performance measures in five areas: access to care, care process, administrative efficiency, equity, and health outcomes. This year it compared statistics in ten countries instead of 11: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. Norway dropped off the analysis list because in 2022 the country exited the International Health Policy Survey. Norway was ranked number 1 in the 2021 analysis. The

One of the most important surveys performed to understand the year-to-year status as well as long-term trends in employer coverage is the Business Group on Health’s annual healthcare strategy survey. The 2025 survey was fielded between June 3 and July 12, 2024. The survey was completed by 125 employers, which cover more than 17.1 million lives in the United States. U.S. and multinational companies completed the survey and range from under 10,000 employees to 100,000 employees and over. About 73% of respondents had more than 10,000 employees. They represent a broad range of industries. Remember that close to a majority of Americans are covered by employer-furnished insurance, usually self-insured ERISA coverage. What does the survey tell us overall? Looking at projected annual increases before plan design changes, the projected trend rose from 6% in 2022 to almost 8% for 2025. Even after design changes, actual healthcare costs continued to grow

I decided to continue my Medicare Advantage (MA) monthly enrollment blogs because of continuing month-over-month increases. The growth is tied to remaining strong benefit packages for 2024.   Many plans will rein in benefits and geographies for contract year 2025 due to significantly deteriorating bottom lines. This is being caused by the return of robust utilization, inflation picking up in the healthcare sector (especially at hospitals), poor Star scores, negative rate increases for 2024 and 2025, new regulatory burdens (such as the new prior authorization restrictions), and the greater costs MA plans will bear due to the Inflation Reduction Act’s (IRA) Part D changes. See my earlier blogs on this Part D topic here: https://www.healthcarelabyrinth.com/will-democrats-be-victim-of-an-october-surprise-of-their-own-making/ and https://www.healthcarelabyrinth.com/part-d-premium-woes-due-to-the-inflation-reduction-act/ . While we are outside of the two regular annual enrollment windows, increases in MA enrollment still occur given the aging of America and the ability of some populations, such as dual eligibles, to continue to make changes

Medicare Advantage (MA) plans are going to want to take note of two recent HPMS memos from the Centers for Medicare and Medicaid Services (CMS). Each touches on major areas of controversy for the program. Supplemental Benefits User Group CMS will host a user group to provide an overview of supplemental benefits data submission for encounter data records on September 26, 2024, 2:00 p.m. – 3:00 p.m. ET. You need to register in advance. See the flyer distributed with the September 10 HPMS memo on the topic. The issue of supplemental benefits is an explosive one right now. Opponents of MA say that MA plans are submitting bids that misrepresent supplemental benefit utilization and thereby inflating their margins. CMS has little to go by because encounter data for supplemental benefits is rarely submitted. CMS did two things to attack the controversial issue. First, it issued a memo requiring plans to submit