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March 6, 2025

Paragon Says Improper Medicaid Payments Could Be Over $1 Trillion The Paragon Health Institute is an extremely powerful think tank with the ear of the Trump administration and some in Congress. Its newest report, in conjunction with the Economic Policy Innovation Center, says that improper payments under Medicaid could be as much as $1.1 trillion over ten years. The Centers for Medicare and Medicaid Services (CMS) estimated improper payments at $543 billion over ten years, but Paragon says that does not include eligibility check errors. The report urges Congress to cut funding to states found with greater than 3% erroneous payments based on eligibility errors. Many of the errors are tied to the suspension of eligibility checks during the COVID pandemic. The ineligible population includes people over income limits and illegal immigrants. The report gives hope that the GOP Congress can reduce Medicaid spending and perhaps certain Medicare spending without

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BCBSA Report A Good Guide To Reasonable Savings

Savings guide from Blue Cross Association is worthy of Congress’ consideration The Blue Cross and Blue Shield Association (BCBSA) has issued a very good report on reasonable healthcare savings that could save nearly $1 trillion over the next decade. I have raised a number of these issues in past blogs, but felt covering them again would be good as the House begins debating spending reductions to hit an $880 billion savings target in the budget reconciliation blueprint passed by the chamber in a very tight vote. BCBSA features ten policy proposals. You can view them in detail at the third link at the end of the blog. As BCBSA notes, the $1 trillion figure over a decade is not federal budget savings alone. It breaks down as such: Site neutral payments As I have suggested on numerous occasions, BCBSA proposes sweeping adoption of site neutral payments in Medicare. BCBSA says

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March 5, 2025

Budget Reconciliation And DOGE Updates Two key developments on the spending reduction front. Republican senators met with Elon Musk on his Department of Government Efficiency (DOGE) commission reductions. Many senators, rightists and moderates, told him that Congress must sign off on the reductions. On one hand, the senators were asserting their branch’s constitutional authority. On the other, they said it insulates the DOGE cuts from court attacks. Musk was open to Senate approval but indicated he did not think some of the reductions had to come back to Congress. He also was surprised that a rescission package can be passed by just a majority vote. Rescission is authorized by the Impoundment Act of 1974. Some House Republicans want to repeal the rescission process to allow the president to exercise what they see as the president’s inherent impoundment authority. It is ironic that the same act could be used to validate

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March 4, 2025

Tariff Costs Likely Passed Through On Drugs And Medical Devices Drug and device makers abroad will be levied a tariff if their imported product origin is Mexico, Canada or China and the costs are likely to be passed through to consumers. This means various providers, including hospitals and physicians, will see cost increases. The costs, too, would be passed through in the drug channel, ultimately hitting employer groups, government programs, and consumers. Consumers could see higher premiums as well as cost-sharing hikes. Canada and Mexico will have 25% tariffs under the Trump administration’s announcement this week. China has total tariffs since September of 20% or more as well. (Article may require a subscription.) #healthcare #drugpricing #tariffs #hospitals #physicians https://www.modernhealthcare.com/digital-health/tariffs-mexico-canada-cardinal-intuitive Healthcare Entities Could See Pressure On Margins If Medicaid Cuts Pass While healthcare entities would not have major shifts in 2025, Medicaid cuts could mean pressure on margins according to Fitch,

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March 3, 2025

House Dems Run Spending Cut Ads In Swing Districts A House Democratic campaign organization officially kicked off the 2026 elections by running a television advertising blitz hitting House Republicans over the prospect of Medicaid cuts in budget reconciliation. The ads are running in 23 swing districts in 13 states. (Article may require a subscription.) #medicaid #election2026 #budgetreconciliation https://www.modernhealthcare.com/politics-policy/medicaid-cuts-tv-ads-gop BCBSMI Had Major 2024 Loss Blue Cross Blue Shield Michigan (BCBSMI), a top insurer in the nation, reported a $1.03 billion loss in 2024 due to rising costs and what it called “unsustainable” market conditions. It had revenue of $40.6 billion. It said the costs were driven by rising utilization of expensive medical services and costs for prescription and specialty drugs. Additional article: https://www.modernhealthcare.com/insurance/blue-cross-michigan-2024-healthcare-costs (Some articles may require a subscription.) #healthplans #margins #bcbsmi https://www.beckerspayer.com/payer/bcbs-michigan-posts-1b-loss-in-2024.html SNP Plans Grow In Enrollment Season While enrollment growth in Medicare Advantage (MA) was lower than previous years,

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Health Insurer Struggles Prominent In 2024

The seven publicly traded national plans had a rough 2024 and hope to realign in 2025 I often talk about the nine major health insurers prominent at the national level in Medicare Advantage (MA). Seven of them are publicly traded while two – integrated delivery system Kaiser Permanente and Big Blue mutual Health Care Service Corporation — are non-profits. Four of the seven actually are owned by large vertically integrated companies. With the close of 2024 and reporting of final results, I thought it would be good to recap performance of the seven publicly traded big national companies. The Healthcare Dive had a great article summing it all up. I substantially based this blog on its analysis, which is at the link at the end of this blog. The insurers The results by and large show the seven insurers had a fairly troublesome 2024 but hope to realign and improve

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February 28, 2025

More 2024 Insurance Financial Results A number of additional health plans announced financial results for 2025. Clover Health’s stock dipped Feb. 28 after the company announced an earnings per share loss and a 2% miss on quarterly revenue. But the company reported a full-year 2024 adjusted EBITDA of $70 million, a huge year-over-year increase of $112 million. Alignment Healthcare achieved its first year of positive adjusted EBITDA as a company. It also reported a huge surge in enrollment. Blue Cross Blue Shield of Massachusetts reported a $400 million operating loss in 2024, driven by spending on GLP-1 medications and other rising medical costs. The company posted a -4.3% operating margin in 2024, compared to a 0.4% margin in 2023.  In other news, Becker’s reports on Blues’ MA enrollment as well as insurers who gained and lost membership for 2025 in MA. Additional articles: https://www.fiercehealthcare.com/payers/clover-health-nets-70-million-adjusted-ebitda-misses-revenue-goals and https://www.fiercehealthcare.com/payers/alignment-healthcare-posts-701-million-quarterly-revenue-beats-expectations and https://www.beckerspayer.com/payer/bcbs-massachusetts-reports-400m-loss-driven-by-glp-1-spending.html and https://www.beckerspayer.com/payer/bcbs-plans-ranked-by-medicare-advantage-members-2025.html #healthplans

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February 27, 2025

Another Study Shows Impact Of Medicaid Reimbursement Cuts To States A second study finds the major impact of reducing federal dollars for Medicaid to states. States that expanded Medicaid coverage could have to find $44.3 billion annually in state budget cuts or increased revenue to maintain what they have. The Urban Institute and Robert Wood Johnson Foundation (RWJF) say state spending would be hiked by about 25.6% on average if that occurred. Twelve states have trigger laws that would drop the expansion if the enhanced reimbursement is halted. I told you yesterday about a Kaiser Family Foundation (KFF) analysis of the spending reductions related to a Medicaid per capita cap program. KFF finds that capping per enrollee spending could reduce federal Medicaid expenditures by $532 billion to nearly $1 trillion over 10 years depending on how states respond. KFF also finds that eliminating the Medicaid expansion matching rate as well

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Medicare Advantage Enrollment Results Show The Struggle In The Industry

Medicare Advantage plans’ financial woes hit 2025 enrollment growth in a big way The long delayed 2025 Medicare Advantage (MA) enrollment season results have finally been published. The January 1 enrollment statistics were up for a short time only to be taken down due to errors and presumably the transition in the White House. This week, both the January and February 2025 results were posted by the Centers for Medicare and Medicaid Services (CMS). In looking at the January results, they do not seem quite right as the growth in enrollment from January to February would be extremely high – rather unprecedented. That leads to my supposition that the January data are still wrong or CMS had major issues processing January 1 applications. As such, I am comparing January 2024 numbers to February 2025 numbers as a proxy for 2024 to 2025 year-over-year growth. The statistics show some of the

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February 26, 2025

MA Growth Down Markedly In Enrollment Season The Centers for Medicare and Medicaid Services (CMS) finally published some data on the 2025 enrollment season and growth is down considerably. This is likely tied to the financial crisis in the industry. The January report still seems to have issues so many analysts are either comparing February 2024 to February 2025, January 2024 to February 2025, or a month in late 2024 to February 2025. I will have a comprehensive blog on this subject tomorrow. Different outlets have ranges of numbers in their coverage. My calculation is that enrollment grew about 4.4% from January 2024 to February 2025. This is down from 8.7% in 2024 and 6.1% in 2022. Of the big nine national health plans, seven gained enrollment from January 2024 to February 2025. But just five of them gained from December 2024 to February 2025. In other news, the Kaiser

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