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Smaller businesses could drop traditional coverage My September 7 blog on being priced out of healthcare ( https://www.healthcarelabyrinth.com/we-are-being-priced-out-of-healthcare-and-it-is-not-just-an-exchange-problem/ ) made the case that the affordability crisis went far beyond the Exchange subsidy debate. The bigger crisis we have is with employer coverage, where most Americans get their insurance. We also have a growing underinsured crisis as huge annual spending trends hit employers. Employers can only absorb so much. Eventually, the math catches up with everyone. Two recent developments make me even more concerned that we are approaching a genuine crisis. The first involves something most Americans have probably never heard of: the No Surprises Act’s federal arbitration process. The second is much easier to understand. Small and midsize employers are increasingly saying they may simply stop offering traditional health insurance. Those two developments may seem unrelated. They aren’t. They are two different manifestations of the same problem: Healthcare costs are

CMS and 37 states are taking a hard look at Medicaid quality measurement. The opportunity is much bigger than simply eliminating paperwork. For years, Medicaid has had a quality problem. There has been no shortage of quality measures, reports, audits, core sets, HEDIS measures and external quality reviews. The problem is that all of that measurement has not necessarily translated into better health outcomes. Now, the Centers for Medicare and Medicaid Services (CMS) is trying to change that. On September 25, CMS announced its Investing in Health Outcomes initiative, with 37 states signing a voluntary Medicaid Quality Pledge. Those states represent approximately 56 million Medicaid and CHIP beneficiaries and about $701 billion in Medicaid spending during fiscal year 2024. The focus is long overdue. A CMS analysis of Medicaid managed care programs across 42 states found approximately 450 quality reporting requirements representing about 260 unique quality measures. Many focus on

September enrollment shows a dramatic slowing going into open enrollment, 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 September 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

Despite the bombast, growing concern at the White House on AI Last week, I wrote an in-depth blog here ( https://www.healthcarelabyrinth.com/ai-in-healthcare-innovate-but-with-guardrails/) urging a risk-based guardrail approach to AI regulation in light of Anthropic CEO Dario Amodei’s plea for an AI oversight game plan. At the time, President Donald Trump dismissed the calls, arguing the fears are overblown and we cannot lose the AI race to China. Trump continues to call the concerns a hoax and fabrication, but there is now reason to believe that the White House really does see apparent risks. On Saturday, with much fanfare, Trump announced that he is creating a new “AI Force” similar to the Space Force as well as appointing an AI czar “to regulate and grow artificial intelligence.” Although Trump does not acknowledge it, it is a bit of a flip-flop. The administration is known to be deeply divided on the potential risks

Attacking health plans is fashionable, but calling them the bogeyman detracts from real reform In various cultures, a bogeyman is a shapeless monster used to scare children into good behavior. And there is little question that politicians – from Donald Trump to Democrats to Republicans — increasingly cast health plans as bogeymen in the debate over affordability. For Democrats, health plans have always been the evildoer. Democrats and other critics argue that insurers are earning enormous profits, wasting huge amounts on administration, and essentially ripping off consumers. But Republicans increasingly talk of health plans as responsible for the affordability crisis as well, frankly because they have done little to remedy the problem. Indeed, just as insurers were registering terrible margin numbers, President Trump repeatedly criticized insurers, saying they are making “billions and billions of dollars.” He argued that government healthcare money should go directly to individuals rather than insurers. A

AI is here to say, but Dario Amodei’s admonition needs to be taken seriously. The debate over artificial intelligence just took another major turn. Anthropic CEO Dario Amodei, one of the people at the center of the AI revolution and one of its most thoughtful leaders, has issued another major warning about where AI could be heading. His message is not that we should abandon AI. Amodei has been outspoken about AI’s extraordinary potential to accelerate science, medicine, and economic growth. His concern is that capabilities may be advancing faster than our ability to understand and control the risks. In an essay, he said that, unless development slows and safeguards are put in place, rogue bots could take over the web in a few short months or bad actors could seize control of AI tools. His proposed reforms include having outside evalulators gain access to each froniter lab to ensure

While cut points and averages surged, a lot goes into whether overall ratings will go up as well. Plan Preview 2 is here and today I am covering two topics. 1 – What will the Centers for Medicare and Medicaid Services (CMS) do on the Stars Ratings front? 2 – What do the cut points, average values, and average ratings tell us about whether overall ratings will go up? What will CMS do on Star Ratings? As we know, when the Clover lawsuit decision occurred, CMS quickly moved to recalculate a Clover contract using the court Clover Specific remedy. A short time later, CMS recalculated all other contracts using a “better of” Original Ratings and a CMS Recalculation methodology that simultaneously conformed with the court decision and ignored it. Three new lawsuits emerged, which are pending now. First, Elevance Health is arguing that it deserves a recalculation based on the

Huge surges annually in employer healthcare costs continue to drive an affordability crisis. I have been writing a great deal lately about the coming coverage crisis in America. Much of the attention — understandably — has been focused on the Affordable Care Act (ACA) Exchanges and the expiration of the enhanced premium subsidies. Roughly 24 million Americans are enrolled in Exchange coverage, and the loss of enhanced subsidies will have a profound impact on affordability and enrollment. I have argued that this is bad policy. While I support reforms to the enhanced subsidies, including requiring everyone to contribute something toward coverage and instituting much stronger fraud and enrollment controls, allowing affordability to deteriorate dramatically makes little sense. But there is a much bigger healthcare affordability story developing. It affects the more than 164 million Americans who receive health insurance through an employer. That makes employment-based insurance, by an enormous margin,

Strap in for the Clover Stars roller coaster ride. We are still violently looping around. Just when you thought the Clover Health Star Ratings saga could not get any more complicated, it has. In my August 17 blog on the fallout from the Clover decision, I laid out again what I call the growing “balkanization” of Medicare Advantage (MA) Star Ratings. We effectively have different potential rating scenarios depending on which interpretation of the Clover decision is applied. And different health plans are now in court seeking the calculation that benefits them the most. Since then, we have had three important developments. First, the SCAN Health Plan and Alignment Healthcare cases are moving forward in Washington, D.C. Second, a federal judge denied Elevance Health’s request for a preliminary injunction, but gave Elevance some very encouraging language on the merits. Third, the Centers for Medicare and Medicaid Services (CMS) has now

The House still looks very likely to flip to Democratic control, with the Senate still in limbo As the midterms approach, I always give you a fresh look at what could happen in terms of control of Congress. Back on June 8 I did my last forecast. I likely will do this again in late September and more frequently after that. As I have said, healthcare will be a big part of how votes are cast in November. Affordability overall is a top issue this election year and healthcare affordability dominates this issue in many ways. The GOP at a disadvantage As I have said in past blogs on the midterms, the GOP has a huge uphill battle to keep control of both chambers. I looked at every midterm election since 1934. No matter how popular a president might be, only on two occasions has the party in control of