Category Archives: Health Insurance Industry

Health Insurance Industry Promises Reforms After $476 Million PR and Lobbying Campaign

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Denial, Health Insurance Industry, Health Insurance Premiums, Health Policy, Healthcare Reform, Lobbyist, Pharmacy Benefits Management, Profit, Profit Margin, Profit Motive • Tagged , , , , • Leave a comment
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Health insurers and their lobbying arms have spent $476.5 million since 2020 to block reform, protect profits, and mislead the public — and it’s coming straight from our premiums and tax dollars.

AHIP, the big PR and lobbying outfit for most health insurers, undoubtedly believes the praise it got from Trump administration officials and some members of Congress this week – when it announced changes insurers presumably will make voluntarily to alleviate the burden of prior authorization demands on patients and health care providers – has taken the heat off insurers. AHIP’s message to Washington politicos: You don’t need to pass any new laws to make us do the right thing. You can trust us, despite our decades of engaging in untrustworthy behavior to maximize profits.

As former health insurance executive Seth Glickman, M.D., explained yesterday, nobody should believe this hen-house guarding fox.

After all, AHIP is nothing more than a PR and lobbying shop with millions of our dollars to play with. It has zero ability to force insurers to do what AHIP claims they will do. I know this because I worked closely with AHIP during my 20 years in the industry and represented Cigna on its strategic communications committee.

From Fox to “Fixer”?

AHIP pulled off its big show on Monday – and got plenty of generally fawning press coverage – because of all the money it and affiliated insurers throw around Washington every year to protect what has become an incredibly profitable status quo.

Collectively, the seven biggest for-profit insurers reported $70 billion in profits last year.

(Beleauered UnitedHealth alone reported $34.4 million in operating earnings.) And that’s just seven among dozens. One way they make that kind of dough, for their shareholders and top executives, is by using prior authorization to avoid paying for patients’ medically necessary care. Many people die as a result, while investors get richer. It’s that simple and that cold.

So just how much money does AHIP and the insurance industry spend to bamboozle members of Congress and the White House every year? We’re talking stupid money. And orders of magnitude more than nonprofits that advocate for reforms that would benefit patients instead of shareholders.

Nearly Half a Billion Ways They Tip the Scale

To find out just how much, I turned to OpenSecrets and did some math. OpenSecrets, as a reminder, is the well-named organization that keeps tabs on campaign contributions and lobbying expenses.

What I discovered is that AHIP has spent almost $65 million lobbying Congress and the Biden and Trump administrations since 2020. Its cousin, the Blue Cross Blue Shield Association, has spent even more. More than twice as much more.

And that, folks, is just the tip of the iceberg, and it doesn’t even include the tens of millions the industry spends on massive advertising campaigns inside the DC beltway that it’s not required to report. Or the dark money ads and advocacy the industry bankrolls.

But just the lobbying totals are mind-blowing. When you factor in the money spent by the big seven insurers and the other PR and lobbying groups that insurers funnel money to, the total grows to almost $500 million. You read that right: nearly half a billion dollars.

Most of that spending was during the Biden administration, but the industry is on track to break spending records during the first year of the current Trump administration. They are lobbying not only to beat back new laws and regulations that could constrain their prior authorization practices but also to protect their biggest cash cows: Medicare Advantage and their pharmacy benefit managers (PBMs).

Three PBMs – owned by Cigna, CVS/Aetna and UnitedHealth –control 80% of the pharmacy benefit market and determine which drugs we’ll have access to and how much we have to pay out of pocket even with insurance.

The Big Number

$476.5 million – That’s the amount of money health insurance corporations and four of their PR and lobbying groups – AHIP, BCBSA (which includes contributions from Elevance/Anthem as well as numerous other BCBS companies), the Pharmaceutical Care Management Association and the Better Medicare Alliance – have collectively spent on lobbying Congress and federal regulators between January 1, 2020, and March 31, 2025.

The Breakdown

Lobby dollars spent by AHIP; BCBSA; BMA; PCMA; Centene; Cigna; CVS/Aetna; Humana; Molina; and UnitedHealth between January 1, 2020, and March 31, 2025.

Keep in mind that that money is not coming out of executives’ paychecks. It’s coming out of our pockets. Insurers skim money from our premiums and taxes to finance their propaganda and lobbying efforts to keep the gravy train rolling. And it’s in addition to all the campaign cash they dole out every year, which I tabulated recently.

This is not to say that reform is impossible. Scrappy advocacy groups with a tiny fraction of that total have scored important victories over the years. But it is why progress is so slow and setbacks are so frequent.

But just imagine how all that money could be put to better use to ensure that all Americans, including those with insurance, are able to get the care they need when they need it. It’s clear that in addition to reforming our health care system, we need political reforms that make it more difficult for big corporations and their trade groups to influence elections and public policy.

Republicans Are Turning on Medicare Advantage

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UnitedHealth Group and the other insurance giants running the Medicare Advantage (MA) program might want to start paying attention to something they haven’t worried much about before: growing skepticism from Republicans.

Until recently, efforts to reform MA — a privatized version of Medicare now covering more than half of all beneficiaries — came mostly from Democrats and independent policy experts.

No longer. The latest skepticism is not coming from a liberal think tank or a progressive PAC. It’s coming from two Republican doctors who have spent decades treating patients and sit on powerful House committees overseeing health care. It’s coming from a former Republican congressman who was an author of the law that established Medicare Advantage two decades ago. And it’s coming from right-leaning organizations and policy experts who are now demanding major changes to MA. Their position marks a dramatic and important shift that could lead to meaningful reforms being enacted in a Congress controlled by Republicans.

An Architect of MA Speaks Out

In an op-ed published by The Hill Sunday, former Republican Rep. Jim Greenwood of Pennsylvania — who helped write the Medicare Modernization Act that created Medicare Advantage — said plainly: “The program no longer lives up to [its] promise.”

Greenwood wrote that he had once believed private competition would drive innovation and efficiency. But today, he says, MA has been overtaken by “a handful of massive insurers who are gaming the rules for profit.” Overpayments, cherry-picking, and risk-score manipulation, he said, are now “endemic.”

“It pains me to say this, but the system we helped create is being abused. And it’s not just hurting taxpayers. It’s hurting patients.”

“Seniors… are too often finding out — at the worst possible time — that their plan won’t cover what they need.”

While Greenwood still believes there is a place for private-sector involvement in Medicare, he now calls for rigorous oversight, transparency, and enforcement. He also warns against insurers’ predictable scare tactics whenever reform is on the table.

“I never imagined that Medicare Advantage would become a vehicle for such waste and abuse,” Greenwood concluded. “It’s time to fix it.”

Republican Congressional Docs Say Medicare Advantage Is Broken

Another recent op-ed, written for The Washington Times by two conservative Republicans, Rep. Greg Murphy of North Carolina and Rep. John Joyce of Pennsylvania – both physicians and co-chairs of the GOP Doctors’ Caucus — draws the same conclusion: Medicare Advantage veered too far off course, and it’s time to rein it in. They wrote: 

“Profit-driven insurance companies have destroyed [Medicare Advantage’s] model.”

“These plans must stop seeing rewards for delaying or altogether denying care to beneficiaries that need it.”

They called out insurers for “upcoding” — the practice of exaggerating how sick patients are to collect more taxpayer dollars — and for using prior authorization as a weapon to delay or deny necessary care to America’s seniors.

These aren’t unsubstantiated complaints. Recent media investigations found that MA plans regularly reject claims that would be approved under traditional Medicare. The Department of Health and Human Services Inspector General has raised alarms, and the U.S. Justice Department has set its sights on UnitedHealth Group’s Medicare business in particular.

And according to the Medicare Payment Advisory Commission (MedPAC), MA is now costing taxpayers 22% more per beneficiary than traditional Medicare — a difference that translates to $83 billion in overpayments to private health insurers last year alone.

Now, Republicans like Murphy and Joyce are saying the quiet part out loud: MA is making insurance company executives and investors rich at the expense of seniors, people with disabilities and taxpayers.

Conservative Advocacy Voices Are Speaking Up, Too

Phil Kerpen, president of the conservative group American Commitment, warned in an op-ed for the Daily Times that Medicare Advantage — which he said was once a “highly innovative and successful” option — is now “becoming increasingly costly and unstable.”

Kerpen pointed to the Department of Justice’s criminal investigation into UnitedHealth as a wake-up call and criticized the monopolistic consolidation of insurers buying up doctors, hospitals, and pharmacies. He called out opaque billing practices, delays in care, and an “unfair burden on taxpayers.”

“If ever there were a government program in need of DOGE-like accountability, competition, and transparency, Medicare Advantage is it.”

He called for reforms many — including myself — have long demanded: stronger disclosure rules, better tools for plan comparison, and serious action on prior authorization abuse. To save the program, he said, President Trump and Congress must be willing to “take on the big insurers and reform it. And quickly.”

Cracks in the Wall of Insurance Influence

There was even a last-minute push, led by Senate HELP Committee Chair Bill Cassidy (R-Louisiana), a doctor, to include MA reforms in Trump’s “One Big Beautiful Bill.” While that effort reportedly failed, Republican critics of the program are vowing to work on a bipartisan basis to enact changes the insurance lobby has fought for years. Upgrade to paid

I spent years in the executive suites of Cigna and Humana — historically big players in Medicare Advantage — and I can tell you this: Republican lawmakers and conservative thought leaders demanding reforms to  MA is no small thing. Private insurance corporations have long counted on bipartisan cover to operate with minimal oversight. If they start losing support from Republicans and conservative media, that protective wall begins to crack.

For years, industry lobbyists succeeded in casting Medicare Advantage as politically untouchable — “too complicated,” “too entrenched,” or “too popular to fix.” But as more members of Congress hear from their constituents about denied care, inadequate provider networks, rising out-of-pocket costs, and profiteering by insurance corporations, that illusion is dissipating.

With GOP leaders like Murphy, Joyce, Kerpen — and now Greenwood — stepping forward, it’s clear the tide is turning. Medicare Advantage reform is no longer a partisan issue — it’s an American issue. And for the sake of patients, taxpayers, and the solvency of the Medicare Trust Fund, it’s time Washington acts like it.

For a Wall Street Lifeline, UnitedHealth Is Throwing Brokers Overboard

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In a concession to Wall Street investors, starting this summer, UnitedHealth will stop paying commissions to agents and brokers for some new enrollees in nearly 200 UnitedHealthcare Medicare Advantage plans across 39 markets.

And it’s happening not because UnitedHealth can’t afford to pay. As we’ve published previously, the company reported $9.1 billion in profits during the first quarter of 2025 — up from $7.9 billion the year before. But that wasn’t enough to satisfy Wall Street, which punished UnitedHealth with the steepest one-day stock drop in 26 years — a $110 billion free fall in market value — after the company revised its full-year profit guidance downward.

Why the drop? 

Because UnitedHealth admitted it may not squeeze quite as much profit from taxpayers this year as expected — mainly due to unexpectedly high care utilization from some of the new Medicare Advantage enrollees it brought on during the last open enrollment period. Particularly enrollees who, as then-CEO Andrew Witty described, came from other insurers exiting the market and hadn’t been properly coded. Yawn.

For Now, Brokers Are UNH’s Patsy

This recent commission cut is less about operational efficiency and more about damage control. UnitedHealth is signaling to investors that it’s willing to shrink its Medicare Advantage footprint — at least temporarily — if that helps preserve profit margins. And Wall Street analysts are eating it up, seeing it as a way to slow the flow of high-cost members and stabilize earnings, according to BarChart.

Off Wall Street, the move has already come under fire. As the National Association of Benefits and Insurance Professionals put it, UnitedHealth is “cutting off the very people best equipped to help” seniors — especially low-income and rural enrollees who depend on brokers to explain their options.

While we would warn seniors against enrolling in a Medicare Advantage plan in the first place – without brokers, many beneficiaries will be left to fend for themselves in a system that’s already infamously confusing, expensive and deadly.

A Strategic Retreat Disguised as a Cost-Containment Strategy

The problem is the perverse incentive structure UnitedHealth and other insurers helped build — one that rewards risk-coding gamesmanship more than it rewards delivering care. For years, the company thrived by maximizing revenue through “coding intensity” and by acquiring everything from doctors’ offices to behavioral health firms to control more of the health care ecosystem.

Now, UnitedHealth is responding the way Wall Street expects: by slashing anything that isn’t bolted down – including brokers.

So here we are: 

UnitedHealth is still wildly profitable, still drawing billions from taxpayer-funded programs like Medicare and Medicaid — and now it’s cutting out the professionals who presumably help seniors navigate a convoluted health care system. All this, mind you, to appease jittery investors. And despite UnitedHealth’s current wobbly share price, analysts expect it to rebound, especially with a continuation of share buybacks on the horizon.

During the first quarter of this year alone, the company bought back $3 billion worth of its own shares. Over the past year, buybacks totaled more than $12 billion. When you factor in dividends, the company said it “returned” more than $16 billion to shareholders in 2024. That’s how you keep investors at least partially satisfied.

Medicare Advantage Is Ripe for an Overhaul 

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Accountable Care Organization (ACO), Competitive Bidding, Health Insurance Industry, Health Policy, Healthcare Reform, Medicare, Medicare Advantage, Risk Adjustment, Standardized Benefits • Leave a comment
Medicare Advantage Is Ripe for an Overhaul 

As the Senate eyes alternative or additional cost-saving provisions to those included in the House-passed reconciliation bill, some Republicans are considering reforms to Medicare. That is a promising development because overhauling Medicare Advantage could lower federal costs in ways that even many Democrats have advocated (although it is certain the overall bill will receive no Democratic support due to myriad other provisions).

Medicare Advantage, or MA, is Medicare’s private insurance option.

Beneficiaries can get their coverage through these plans in lieu of the traditional, government-managed program. Medicare pays MA sponsors a per-person monthly fee, which they use in turn to pay providers for the services their enrollees need. Enrollment in MA surged after Congress amended the payment formula in 2003. According to the 2024 Medicare trustees report, in the last decade alone, MA enrollment increased from 16 million people in 2014, or 30 percent of total enrollment, to 34 million people in 2024, or one out of every two program beneficiaries.

MA is growing because the plans usually offer more generous coverage than the traditional program without charging substantially higher premiums. In fact, many MA enrollees get free prescription drug coverage and much lower cost-sharing for hospital and physician services. They also sometimes get limited dental and vision care protection. MA enrollees usually do not pay for Medigap insurance, which can be expensive.

Critics argue MA plans can offer added benefits only because they are overpaid – a contention credible research confirms, including as conducted by the Medicare Payment Advisory Commission (MedPAC). At the same time, other data shows MA plans are often more efficient at delivering services than the traditional program because the plans scrutinize claims more carefully. High MA enrollment is also associated with positive spillover effects in the traditional program.

MA reforms should incentivize efficiency and high-quality care without needlessly overpaying the plans. The Senate should pull together a reform plan that gradually restructures the MA market so that it operates more efficiently and with lower costs for taxpayers. The following general principles should guide what is developed.

  • Competitive Bidding.
  • MA plans submit bids under the current formula, but Medicare’s payment is a combination of those bids and benchmarks that are set administratively. The Senate should amend the formula to rely strictly on bidding, with a transition to prevent abrupt changes in what is offered to enrollees. The payment could be based on the average bid weighted by enrollment. The new system could be phased in over five years by gradually increasing its influence on the formula (20 percent in year one, going up to 100 percent in year five, for instance).
  • Standardized Benefits.
  • Competitive bidding should be combined with standardization of the coverage MA plans are offering. Without such rules, it is difficult for individual beneficiaries to compare their options on an apples-to-apples basis. The Senate should require CMS to develop a standard MA offering that is comparable in value to the traditional benefit (it may be necessary to add catastrophic protection to the traditional program to ensure the competition is fair). MA plans would then submit their bids based on this standardized offering, and all Medicare beneficiaries would have the option of opting for such coverage. Further, the Senate should direct CMS to develop a small number of standardized supplemental benefits that could be purchased by beneficiaries with additional premium payments. These offerings could focus on the most popular add-ons in the MA market.
  • Risk Adjustment.
  • There are many criticisms of the current system of providing payment adjustments to MA plans based on the varied health risks of their enrollees. The current system has several flaws that might be addressed, but the basic problem is too much reliance on the data submitted by the plans which can lead directly to higher revenue. That design of course invites abuse. The Senate should put into law a requirement that CMA is to determine a final annual risk score for the plans based on submitted information, and any needed refinements by the government to ensure the fairest possible comparisons across plans.
  • ACOs as MA Plans. 
  • The Medicare program would benefit from robust provider-driven MA plans that can effectively compete with the insurer-led MA offerings now dominating the market. CMS should work with interested Accountable Care Organizations (ACOs) on building out functions they would need to become viable alternatives in the MA insurance market.

The Congressional Budget Office (CBO) estimates the House bill will increase deficits by $3.0 trillion over ten years when net interest is in the calculation. Medicare reforms could help the Senate produce a more fiscally responsible bill. If an MA bidding system led to a reduction in payments comparable to a 10 percent cut (which is realistic based on MedPAC’s research), the savings over a decade would be close to $500 billion.

Tariffs drive health plan premium hikes

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Insurance Premiums, High Cost Therapies, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses, Underinsured, Uninsured • Leave a comment

https://www.axios.com/2025/06/18/tariffs-health-insurance-premium-hikes

Health insurers are starting to notify states that tariffs will drive up the premiums they plan to charge individual and small group market enrollees next year.

Why it matters: 

The Trump administration’s trade policy is adding another layer of uncertainty for health costs as Congress considers Medicaid cuts and is expected to sunset enhanced subsidies for Affordable Care Act coverage.

  • “There are sort of a perfect storm of factors that are driving prices up,” said Sabrina Corlette, research professor at Georgetown’s Center on Health Insurance Reforms.

The big picture: 

Health insurers calculate monthly premiums in advance of each year based on the expected price of goods and services and projected demand for them.

  • Tariffs announced by President Trump are expected to drive up the cost of prescription drugs, medical devices and other medical products and services. Some of that difference ultimately would be passed down to enrollees.

Where it stands: 

A handful of health insurers administering individual and small group plans have already explicitly told state regulators that tariffs are forcing plans to raise enrollee premiums more than they otherwise would next year, KFF policy analyst Matt McGough wrote in an analysis published Monday.

  • Independent Health Benefits Corporation told New York regulators in a filing last month that it plans to raise premiums for its individual market enrollees 38.4% next year.
  • About 3% of that is directly due to tariffs, based on projections of how much they’ll increase drug prices and the use of imported drugs, Frank Sava, a spokesperson for Independent Health, told Axios.
  • Similarly, UnitedHealthcare of Oregon said in a filing that nearly 3% of its planned 19.8% premium increase for small group enrollees next year is due to uncertainty around tariffs, particularly on how they’ll affect pharmaceutical prices.

Insurers “don’t have any historical precedent or data to project what this is going to mean for their business and health costs,” McGough said to Axios. “I think it really makes sense that they’re trying to hedge their bets.”

  • Insurers can’t change their premiums throughout the year. But if health plans do overshoot their premium estimates in rate filings, they have to pay enrollees back the difference in rebates.
  • While there may be a competitive advantage to keeping premiums lower, there isn’t really a way for insurers to make up for extra unplanned costs after the fact.

Yes, but: 

Some insurers indicated that while they’re keeping a close eye on tariff-related impacts, they aren’t baking them into their premium rates yet.

  • “There is uncertainty around inflation and the economy due to possible tariffs however we did [not] put anything for this in this filing,” Kaiser Foundation Health Plan of the Northwest’s report to Oregon reads.
  • State regulators can also push back on insurers’ premium calculations before they’re finalized, McGough noted.

What we’re watching: 

While some states have earlier deadlines, insurers have to submit their 2026 ACA marketplace plan rates to the federal regulators by July 16, and proposed rates will be posted by August 1.

  • That’s when we’ll get a better picture of how seriously tariffs are concerning health insurers.

Cost to insure a family tops $35,000

Posted on by • Posted in Employee Raise, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Insurance Premiums, High Deductible Health Plans, High Drug Prices, High Premiums, High Prices, Out of Pocket Expenses, Outpatient Care, Pharmaceutical Industry, Underinsured, Uninsured • Leave a comment
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The cost to cover a family of four through workplace insurance now exceeds $35,000, nearly triple what it cost 20 years ago as annual growth in health costs have far outpaced wages.

The big picture: 

Growing pharmacy and outpatient facility costs drove most of the increase, which includes employee and employer shares, according to the 2025 Milliman Medical Index.

  • Employers have been wary of passing health cost hikes to workers in a tight labor market, but the rising demand for costly care may force a reckoning.

State of play: 

The $35,119 annual cost to cover a hypothetical family of four this year factors in drug costs, inpatient and outpatient care, and professional services, along with an “other” category that includes home health, ambulance transport, medical equipment and prosthetics.

  • A year of health care cost a family of four $12,214 in 2005, the year Milliman launched the index. The 20-year cumulative gain of 188% outpaced the 84% growth in wages over the same time.
  • Health costs have increased about 6% per year on average over the past two decades, according to Milliman, compared with an average inflation rate of 2.5% over that time.

Between the lines: 

Employers in 2025 still shoulder 58% of employee health care costs, but their share has shrunk since 2005, when it was more than 60%.

Reality check: 

Health care costs vary significantly by age, geography and pharmacy rebate arrangements.

  • Milliman calculates family cost based on a family with a 47-year-old male, 37-year-old female, and children ages 4 and under 1.
  • This was a “mathematically average” family in 2005, and Milliman continues to use that formula to keep data comparable year-to-year.
  • The firm has an online tool that allows readers to input other family configurations to see their estimated 2025 health care costs.

The analysis is based on Milliman’s proprietary research tools and analyzes commercial claims data. The family cost figure reflects nationwide average negotiated provider fees and average PPO benefit levels.

They Cut Medicaid, Not the Waste: Congress Protects Big Insurance While Slashing Care

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Healthcare Reform, Lobbyist, Medicaid, Medicaid Cuts, Medicare, Medicare Advantage, MedPAC, Political Action Committees (PAC), Political Lobbying, Pre-Authorization, Profit, Profit Margin, Profit Motive, Super PAC, Upcoding • Leave a comment
https://healthcareuncovered.substack.com/p/they-cut-medicaid-not-the-waste-congress?utm_source=post-email-title&publication_id=255152&post_id=163510896&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

The House of Representatives’ reconciliation bill, passed by the powerful Energy and Commerce Committee today, cuts just about everything when it comes to health care – except the actual waste, fraud and abuse. Now the bill heads to the floor for a vote of the full House of Representatives before it must also be passed by the Senate to become law. 

I know what you’re thinking: not another story about Medicaid. With the flood of articles detailing the devastating Medicaid cuts proposed by House Republicans —cuts that could strip 8.7 million people of their health coverage — there’s an important fact being overlooked: Members of Congress chose to sidestep policies aimed at reining in Big Insurance abuses and, instead, opted to cut Medicaid.

And the real irony of it all is they could have saved a ton of money if they would just address the elephant in the room. 

Abuses by Big Insurance companies have been going on for decades but have only recently come under scrutiny. Insurance companies figured out how to take advantage of the structure of the Medicare Advantage program to receive higher payments from the government.

They do this in two ways:

  1. They make their enrollees seem sicker than they are through a strategy called “upcoding” and;
  2. They use care obstacles such as prior authorization and inadequate provider networks that eventually drive sicker people to drop their plans and leave them with healthier enrollees, referred to as “favorable selection.” 

According to the Medicare Payment Advisory Commission (MedPAC) these tactics lead the government to overpay insurance corporations running MA plans by $84 billion a year. This number is expected to grow, and estimates show that overpayments will cost the government more than a $1 trillion from 2025-2034. That is $1 trillion dollars in potential savings Republicans could have included in their bill instead of cutting Medicaid spending that provides care for vulnerable communities. 

These overpayments do not lead to better care in MA plans; in fact, research has shown that care quality and outcomes are often worse in MA compared to traditional Medicare. Even worse, these overpayments are tax dollars meant for health care that end up in the pockets of shareholders of big insurance corporations, which spend billions of taxpayer dollars on things like stock buybacks and executive bonuses. 

One of the most frustrating parts of the lawmaker’s choice to target Medicaid rather than Big Insurance abuses is that there are multiple policies supported by both Republicans and Democrats to stop these abuses. Sen. Bill Cassidy (R-Louisiana), along with Sen. Jeff Merkley (D-Oregon), have introduced the NO UPCODE Act, which would cut down on the practice of upcoding explained above. President Trump’s Administrator of the Centers for Medicare and Medicaid Services, Dr. Mehmet Oz, said during his confirmation hearing that he supports efforts to crack down on practices used by insurers to upcode. And Rep. Mark Green (R-Tennessee) introduced a bipartisan bill to decrease improper prior authorization denials in MA. 

In a somewhat cruel twist, the only mention of Medicare fraud in the Republican reconciliation bill proposals is a section claiming to crack down on improper payments in Medicare Parts A and B (which make up traditional Medicare) by using artificial intelligence.

The total improper payments in TM represent just over one-third of the overpayments going to MA plans each year, and many of the payments flagged as improper in TM are flagged due to missing documentation rather than questionable tactics that MA insurers use. 

In reflecting on why Republicans in Congress ignored potential savings from Big Insurance reforms and instead pursued cuts to care for people depending on Medicaid, which do not save as much, my biggest question was, why?

Why would lawmakers swerve around a populist policy right in front of them to stop Big Insurance from profiting off of the federal government to instead propose a regressive policy that targets millions of working Americans and leaves health insurance corporations that make billions in profits each year untouched?

Unfortunately, the answer likely lies in money. Although people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) make up roughly one-third of the U.S. population, they account for just 0.5% of all political campaign contributions — about $60 million annually. This disparity is likely driven by financial constraints: Many of these individuals are rightly focused on covering basic needs such as housing, food, and childcare, especially as wages have not kept pace with the rising cost of living.

In contrast, the health care sector — which includes major players like big insurance, pharmaceutical and hospital companies—contributed $357 million during the 2020 election cycle, including $97 million to outside groups such as Super PACs. These outside spending groups are largely funded by corporations and wealthy individuals, who represent less than 1% of the population but wield significant political influence.

Super PACs spent more than $2 billion during the 2020 election cycle, amplifying the voices of industry-aligned donors. This stark imbalance in political spending may help explain why congressional proposals targeted Medicaid recipients while leaving the powerful health insurance industry largely untouched.

It is not only Republicans who have failed to stop Big Insurance from taking advantage of federal health programs, Democrats declined to take action when negotiating their health care legislation during President Biden’s term. Rather, it seems to be a failure of policymakers of both parties to pass legislation that makes it clear to Big Insurance that our health care is not an investment opportunity for Wall Street, and the dollars we pay in taxes to support Medicare are not pocket change for executives to use for stock buybacks.

The failure to include MA reform represents a missed opportunity to prioritize patient care over corporate profits. However, the growing strength and voices of patients across the nation will ultimately make it impossible for lawmakers to ignore this issue much longer. With continued momentum, the fight to put patients over Big Insurance profits will succeed.

Big Shifts: CVS Is Pulling the Plug on ACA Coverage — And 1 Million Americans Will Pay the Price

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Abandon, ACA, Commitment, Congressional Budget Office (CBO), Health Insurance Coverage Adequacy, Health Insurance Industry, High Deductible Health Plans, Out of Pocket Expenses, Profit, Profit Margin, Profit Motive, Underinsured, Uninsured, Vertical Consolidation, Vertical Integration, Wall Street • Leave a comment
https://healthcareuncovered.substack.com/p/big-shifts-cvs-is-pulling-the-plug?utm_source=post-email-title&publication_id=255152&post_id=163399094&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

In what’s becoming an all-too-familiar pattern, CVS Health announced it will pull Aetna out of the Affordable Care Act (ACA) marketplace in 2026, leaving about a million people across 17 states searching for new health coverage — and in some cases, fighting to afford any at all.

This marks yet another retreat by a major for-profit insurer from a program designed to provide affordable health coverage to Americans who don’t get it through work. CVS made the announcement while simultaneously celebrating a 60% increase in quarterly profit and revealing a new deal to boost sales of the pricey weight-loss drug Wegovy through its pharmacy and pharmacy benefit manager (PBM) arms.

Let me repeat that: Aetna is exiting the ACA because it claims it can’t make enough money on people enrolled in those plans, on the same day its parent company posted nearly $1.8 billion in profits in just the first three months of this year. 

This is the same company, by the way, that dumped hundreds of thousands of seniors and disabled people at the end of 2024 because some of them were using more medical care than Wall Street found acceptable. If this doesn’t tell you everything you need to know about who the health insurance industry is really working for, I don’t know what will.

From “Commitment” to Abandonment

Aetna first bailed on the ACA exchanges in 2018, then re-entered in 2022 when insurers could see more clearly how they could make significant profits on that book of business. Now, after just a few years of moderate participation, it’s heading for the exits again. CVS Health executives blamed “regulatory uncertainty” and “highly variable economic factors,” according to a statement to The Columbus Dispatch.

But make no mistake—this was a cold business calculation. Uncertainties and economic variabilities are constants in the insurance game.

CVS’ CEO David Joyner told investors:

“We are disappointed by the continued underperformance from our individual exchange products … this is not a decision we made lightly.”

That’s corporate-speak for “our Wall Street friends weren’t impressed.”

Aetna’s ACA exchange business, covering roughly 1 million people, is just a sliver of CVS’ overall medical membership of 27.1 million. But even though the profits weren’t massive, the people depending on this coverage — many of them self-employed, working multiple part-time jobs, or recently uninsured — will now be thrown into chaos.

And it’s happening at a time when health insurance for many Americans hangs by a thread. Unless Congress acts in the coming months, the ACA’s enhanced tax subsidies—first implemented under the American Rescue Plan—are set to expire at the end of this year. Without them, premiums could spike by 50% to 100% depending on income and geography.

The Congressional Budget Office projects that the lapse in subsidies could leave 3.8 million more Americans uninsured — and now, 1 million more will be forced to find new plans as CVS/Aetna walks away.

Same Song: Prioritizing Profit, Not Patients

Let’s be clear about what CVS is doing here: It’s ditching an essential safety net for millions in order to chase higher profits elsewhere—most notably, in the exploding market for GLP-1 drugs like Wegovy. On the same day it abandoned the ACA, CVS announced a new deal to give Wegovy preferred placement on its PBM formulary, displacing Eli Lilly’s Zepbound. This will help CVS dominate the obesity drug market—and rake in profits through its Caremark PBM and nearly 9,000 retail pharmacies.

It’s a powerful example of vertical integration in action.

CVS owns the insurer (Aetna), the PBM (Caremark), and the pharmacy (CVS retail stores). When it walks away from lower-margin business like ACA plans and doubles down on high-dollar drug deals, we see its true priorities: selling expensive drugs, saddling individuals, families and employers with the costs, and keeping Wall Street happy.

Even worse, the decision is taking place against a troubling political backdrop. The Trump administration has already taken steps to undermine ACA infrastructure and expressed skepticism toward core public health programs. Cuts to navigator funding, changes to vaccine guidelines, and looming uncertainty around tax credits are all part of a slow-motion sabotage of the ACA. This is not to say that the ACA doesn’t have its flaws that need to be addressed.

But instead of penalizing hard-working Americans and their families, lawmakers and the Trump administration should focus instead on lowering the ridiculously high out-of-pocket maximum that the ACA established (and that keeps going up every year) and fixing the medical loss ratio provision that has fueled the vertical integration in the insurance industry.

The Next 100 Days: What Healthcare Should Expect

Posted on by • Posted in Economy, Funding, Health Insurance Industry, Health System, Hospital, Hospital Industry, Investing, Investment, Medicare, Medicare Advantage, Public Health, Public Opinion, Public Perception, Supreme Court, Wall Street • Leave a comment
The Next 100 Days: What Healthcare Should Expect

The Trump administration is moving into its second 100 days facing conditions more problematic than its first 100. For healthcare, this period will define the industry’s near-term future as changes in three domains unfold:

  • The Economy: The economy is volatile and consumer confidence is waning. The impact of tariffs on U.S. prices remains an unknown and escalating tension between the Ukraine and Russia, Israel and Palestine, Pakistan and India are worrisome. Household debt is mounting as student loans, medical debt and housing costs imperil financial security for more than half of U.S. households. The 3 major stock indices remain in the red YTD, prospects for a recession are high and investors are increasingly cautious. Net impact on healthcare organizations and public programs: negative, especially those without strong balance sheets and access to affordable private capital.
  • The Courts: Recent opinions by the Supreme Court and District Courts suggest a willingness to challenge the administration’s Executive Orders on immigrant deportation and due process, threats and funding cuts aimed at law firms and universities considered “woke” and layoffs initiated by DOGE and more. Court challenges will slow the administration’s agenda and create uncertainty in workplaces. Net impact: negative. Uncertainty paralyses planning and operations in every public and private healthcare organization.
  • The Public Mood: The afterglow of the election has dissipated and the public’s mood has shifted from guarded optimism to anxiety and despair. The public’s uncertain about tariffs and worried about household expenses. Net impact: negative. Healthcare affordability and prices are major concerns to consumers: the majority (76%) think the system is more concerned about profitability than patient care (Jarrard).

Current events in these areas portend headwinds for most public and private healthcare organizations where attention in the next 100 days will be focused in these areas:

  • Oversight: New rules, programmatic priorities, key personnel appointments and re-organization in HHS, CMS, the FDA and VA: RFKJ’s MAHA plans and Commission appointees, Oz’ affinity for Medicare Advantage predisposition toward value-based care and Makary’s overhaul of the FDA’s drug oversight process will be “on the table” in the next 100 days.
  • Funding: Healthcare funding in the FY 2026 federal budget. The GOP-controlled House and Senate can pass a budget with minimal support from Dem’s that reflects a serious effort to reduce the federal debt ($37 trillion/123% of GDP– up from $20 trillion in 2017). Healthcare cuts expected to be significant though rumored massive cuts to Medicaid unlikely.
  • States: State healthcare referenda and executive actions: states are evaluating price controls on drugs and hospitals, reparations from insurers for delays and prior-authorizations, scope of practice restrictions and more. Topping the watchlist in most states is Medicaid funding and potential fallout from discontinued ACA marketplace subsidies factored into the FY 2026 budget being finalized by the GOP-led Congress in DC.
  • SCOTUS: Supreme Court decisions will be handed down or before June 30 when SCOTUS’ 2024 term ends including Braidwood Management v. Becerra which will determine whether the Affordable Care Act’s requirement that private insurers cover preventive services without cost-sharing will continue. The court will also opine to the authority of the HHS secretary to appoint members of the U.S. Preventive Services Task Force. The potential impact of these decisions on coverage, insurance premiums and access to preventive health services is pervasive.
  • Financial markets: Capital markets are in a watchful waiting mode as US trade policy unfolds, inflation fluctuates, the fed’s interest rate determination is disclosed and consumer spending reacts. Private investing in healthcare remains opportunistic though deal flow is shifting and risk thresholds tightening.
  • Polls: Polls draw the attention of media and elected officials. They influence how organizations prioritize advocacy strategies, address consumer complaints and concerns and manage reputations. As reflected in numerous national polls, trust in the system and its key players—insurers, hospitals, drug companies—is at a historic low.

Each sector in U.S. healthcare will be impacted differently: Three face the strongest headwinds:

  • Hospitals: Hospitals face enormous financial challenges, especially not-for-profits, safety net, rural and veteran’s hospitals. Last week’s unfavorable SCOTUS decision against hospitals alleging DSH under-payments will cost $1 billion per year. Congressional adoption of site neutral payment policy could cost $15 billion/year. Drug prices, labor costs, insurer payment cuts and red-tape will negate operating margins and lower investment income knee-capping growth and innovation plans. Complicating matters, employed physicians will demand higher pay and more control.  And Congressional budget-creators believe the sector’s 31% share of total healthcare spending makes it ripe for cuts attributable to “waste, fraud and abuse”.
  • Insurers: Medicare Advantage (which enjoys support by key administrators including CMS’ Mehmet Oz) has become a lightening rod of insurer criticism alongside prior authorization policies that restrict care. Coverage remains key to household financial security but insurers are seen as barriers to rather than facilitators of evidence-based cost-effective care. And the concentration of power in corporate titans (United, Humana, Cigna, CVS, Centene and others) is viewed with skepticism.
  • Public Health: Public health is not a priority in the U.S. health system despite recognition that social determinants account for 70% of the system’s $5 trillion spending. Most programs are funded by state and local governments with federal support limited. Public health is not seen as an investment and, in some settings treated with disdain as welfare or waste. As Mayors and Governors develop plans for the rest of 2025 and through 2026, public health cuts will be likely as federal co-funding becomes scarce.

The next 100 days will define the national agenda for the mid-term election in November 2026, reflect the solidarity of the MAGA movement and show the impact of tariffs on inflation, consumer prices and the public’s mood.

Healthcare leaders will be watching closely. All will be impacted.

Medicare Scramble: Wall Street Wants Insurers to Dump Costly Seniors

Posted on by • Posted in Health Insurance Coverage Adequacy, Health Insurance Industry, Health Insurance Premiums, High Premiums, High Risk Patients, Lobbyist, Medicare, Medicare Advantage, Preexisting Conditions, Profit Motive, Underinsured, Wall Street • Leave a comment
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Wall Street is speaking loudly to Medicare Advantage insurers: If you want us to stick with you, keep dumping seniors who are pinching your profit margins. 

Investors continue to punish UnitedHealth Group since the company downgraded its 2025 profit expectations on April 17. On Friday, UnitedHealth’s stock price hit not only a 52-week low—$393.11—but its lowest point in years. The last time UnitedHealth’s stock price went below $400 a share was on October 14, 2021. 

The company’s shares lost nearly 4.5% of their value during the past week, contributing to a decline that started soon after the company set an all-time high of $630.73 last November. UnitedHealth’s shares have lost more than 33% of their value since then. 

Wall Street Sends a Message

Meanwhile, investors have once again embraced UnitedHealth’s top two rivals in the Medicare Advantage business–Humana and CVS/Aetna. Those companies told investors last year, when both were in the Wall Street dog house for spending more than investors expected on patients’ medical care, that they would dump hundreds of thousands of their costliest Medicare Advantage enrollees to improve their profits. They made good on that promise, shedding almost 650,000 seniors and people with disabilities by the end of the year. 

Many of those people enrolled in a UnitedHealth Medicare Advantage plan. The company reported 400,000 more Medicare Advantage enrollees in the first quarter of 2025 than in the fourth quarter of 2024. That used to be a good thing, but UnitedHealth’s executives told investors on April 17 that it wouldn’t make as much money for them as the company had assured them just three months earlier because it likely will have to spend more than they expected on those new MA enrollees’ medical care. Investors responded by immediately dispatching the company’s shares to the cellar. Those shares lost about 23% of their value in a single day.

The Street had also punished Humana and CVS last year when they said they were paying more for seniors’ medical care than they’d expected. Shares of both companies cratered, losing around half their value. So, executives at both Humana and CVS started identifying Medicare markets to get out of entirely. The culling was ruthless. CVS shed 227,000 MA enrollees. Humana got rid of 419,000.

Locked Out of Traditional Medicare

Those seniors and disabled people had to scramble to find a new Medicare Advantage insurer because it is difficult for most people to go back to traditional Medicare and find an affordable Medicare supplement policy. Medicare supplement insurers must waive underwriting during the first six months of applicants’ eligibility for Medicare, but people who enroll in a Medicare Advantage plan and want or need to make a change months later find out that insurers will charge them more unless their health is nearly perfect. 

Of the seven big for-profit health insurers, four (Cigna, CVS/Aetna, Humana and Centene) collectively cut 1.3 million of their Medicare Advantage enrollees adrift at the end of 2024 in an effort to stay in Wall Street’s good graces. Cigna dumped all 600,000 of its MA enrollees, selling them to the Blue Cross corporation HCSC. For-profit Blue Cross insurer Elevance picked up 227,000; Molina added 18,000, and, as noted, UnitedHealth signed up 400,000 new MA enrollees. 

While UnitedHealth’s shares have lost a third of their value, CVS’s shares have increased more than 50%  since the first of this year. They even set a 52-week high of $72.51 on Thursday. Humana’s shares closed Friday at $258.48, up 1.88% since January 1. They are out of the Wall Street dog house – for now, anyway. 

Profits, Lobbying Soar

I trust you are not feeling sorry for UnitedHealth because of its misfortune on Wall Street. It is still a hugely profitable company–just not profitable enough lately to please investors. This huge corporation, the fourth largest in America, reported $9.1 billion in profits in just the first quarter of this year. If the company makes it more difficult for its health plan enrollees to get the care they need this year, it could make even more than the $34.4 billion in profits it made last year. 

And as a group, the seven big for-profits, including those that spent more than Wall Street felt was necessary on patients’ medical care, made $70 billion in profits last year. (UnitedHealth made nearly as much as the other six combined.)

And collectively, those giant corporations took in a record $1.5 trillion in revenue from us as customers and taxpayers last year. They are doing quite well. But that won’t stop them from trying to keep lawmakers and Trump administration officials from cracking down this year on the widespread waste, fraud and abuse in the Medicare Advantage program. You can expect them to spend a record amount of our money on lobbying expenses in Washington this year to keep their Medicare Advantage cash cow well fed.