Tag Archives: Politics

July 2025 Actions are the Turning Point for U.S. Healthcare

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid Cuts, Medicaid Funding, Medicare Cuts, State of the Union, Turning Point • Tagged , , , , • Leave a comment
July 2025 Actions are the Turning Point for U.S. Healthcare

July 2025 will be the month U.S. healthcare leaders recognize as the industry’s modern turning point. Consider…

  • On July 4, the One Big Beautiful Bill Act was signed into law setting in motion $960 billion in Medicaid cuts over the decade and massive uncertainty among those most adversely impacted—low income and under-served populations dependent on public programs, 8 to 11 million who used now-suspended marketplace subsidies to buy insurance coverage, and hundreds of state and local health agencies left in funding limbo.
  • On July 15, the Bureau of Labor Statistics reported the June Consumer Price Index rose .3% bumping the LTM to 2.7% (lower than LTM of 3.4% for medical services). Prices have edged up.
  • On July 31, President Trump issued an Executive Order to 17 drug companies ordering them to reduce prices on their drugs by September 29 or else. And CMS issued final rules for FY2026 Medicare payments to hospitals, rehab and other providers reflecting increases ranging from 2.5-3.3% effective October 1.
  • And on the same day, the Bureau of Labor issued its July 2025 jobs report that showed a disappointing net gain of 73,000 jobs plus downward revisions for May and June of 258,000 sparking Wall Street anxiety and President Trump to call the results “rigged” before firing BLS head Erika McEntarfer. Note: healthcare added 55,000 in July—the biggest of any sector and more than its 42,000 average monthly increase.

Collectively, these actions reflect rejection of the health industry by the GOP-led Congress.

It follows 15 years of support vis a vis the Affordable Care Act (2010) and pandemic recovery emergency funding (2020-2021). In that 15-year period, the bigger players got bigger in each sector, investment of private equity in each sector became more prevalent, costs increased, affordability for consumers and employers decreased, and the public’s overall satisfaction with the health system declined precipitously.

For the four major players in the system, the passage of the “big, beautiful bill” was a disappointment. Their primary concerns were not addressed:

  • Physicians wanted relief from annual payment cuts by Medicare preferring reimbursement tied directly to medical inflation. And insurer’ prior authorization and provider reimbursement was a top issue. Status: Not much has changed though adjustments are promised.
  • Hospitals wanted continuation of federal Medicaid funding, protection of the 340B drug purchasing program, rejection of site-neutral payment policies, higher Medicare reimbursement and relief from insurer prior authorization frustrations. Status: Medicaid funding is being cut forcing the issue for states. CMS payment increases for 2026 are lower than operating cost increases. Insurers have promised prior-auth relief but details about how and when are unknown. And Congress posture toward hospitals seems harsh: price transparency compliance, safety event reporting, and cost concerns are bipartisan issues.
  • Insurers wanted sustained funding for state Medicaid and Medicare Advantage programs and federal pushback against drug prices and hospital consolidation. Status: Congress appears sympathetic to enrollee complaints and anxious to address insurer “waste, fraud and abuse” including overpayments in Medicare Advantage.
  • Drug companies oppose “Most Favored Nation” pricing and want protections of their patents and limits on how much insurers, pharmacy benefits managers, wholesalers, online distributors and other “middlemen” earn at their expense. Status: to date, little action despite sympathetic rhetoric by lawmakers. Status: to date, Congress has taken nominal action beyond the Inflation Reduction Act (2022) though 23 states have passed legislation requiring PBMs, insurers and manufacturers to disclose drug prices and 12 states have established Prescription Drug Affordability Boards to monitor prices.

My take:

The landscape for U.S. healthcare is fundamentally changed as a result of the July actions noted above. It is compounded by public anxiety about the economy at home and global tensions abroad.

These July actions were a turning point for the industry: responding appropriately will require fresh ideas and statesmanship. Transparency about prices, costs, incentives and performance is table stakes. Leaders dedicated to the greater good will be the difference.

Expect More Hunger in America with Big New Rips to the Safety Net

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Health Policy, Healthcare Cuts, Healthcare Reform, Hunger, Medicaid, Medicaid Cuts, Medicaid Eligibility, Medicaid Funding, Medicaid Work Requirements, Public Good, Public Health, Public Interest, Public Welfare, Safety Net, Supplemental Nutrition Assistance Program (SNAP) • Tagged , , , , • Leave a comment

https://healthcareuncovered.substack.com/p/expect-more-hunger-in-america-with

The recently passed One Big Beautiful Bill Act, which makes deep cuts to the Medicaid program, also puts the food assistance that 41 million low-income Americans rely on in jeopardy. Many of the families currently getting food provided by  the Supplemental Nutrition Assistance Program (SNAP) stand to lose that support.  

SNAP may well disappear for some families as the federal government moves to trim it. “The cuts are massive and extremely cruel when families need more support, not less,” says Signe Anderson, senior director of nutrition advocacy, at the Tennessee Justice Center in Nashville. 

Government food assistance was established during the Great Depression, but it wasn’t until 1977 that the program became more accessible when the requirement that recipients had to pay for a portion of their food stamps was ended. Throughout its history, foes of the program have tried to dismantle it and may have succeeded as a result of provisions in the bill President Trump signed on July 4. 

The new legislation calls for cutting spending for food stamps by $186 billion through 2034. “Everyone on food stamps will be affected in some way, and many will lose benefits,” Anderson says. “I don’t think the Congress understands the level of necessity in the community for food, health care and mental health treatment, some for the rest of their lives.” 

One major change is being made to work requirements that have historically been part of the Medicaid program, which is administered and partially funded by the states. Anderson points out that under the new arrangements, participants may find the task of enrolling and staying enrolled more onerous. “We see a lot of people cut off already because too many life circumstances make it difficult for them to meet work requirements.”  

Indeed when you look at the changes to SNAP, the first word that might come to mind is ‘draconian.’

To receive benefits those new to the program, and those already on it who are between 55 and 64 and do not have dependent children or who have children 14 and older, will have to prove they work. Or they will have to volunteer at least 20 hours a week or enroll in training programs. Parents of school-aged children will now be required to work.

Some five million people, including about 800,000 children and about a half million adults who are 65 and older, could lose their food benefits.  

The programs the new law targets have been a lifeline for some. Nikole Ralls, a 43-year-old woman in Nashville, who was once a drug addict but now counsels others who need help, says, “I got my life turned around because of Medicaid and SNAP.”  

In a recent memo to state agencies administering the SNAP program, Agriculture Secretary Brooke Rollins said she was concerned about what was described as abuse of the waiver system by states, noting that the new approach for the SNAP program would prioritize work, education and volunteering over what the department characterized as “idleness and excessive spending.” 

Anderson said, “The public doesn’t understand what hunger looks like and are misinformed about how well-run and streamlined the SNAP program is.”   

“Most of the people who can, do work.  We have parents working two and three jobs,” Anderson said. For families in this predicament food banks, which have become default grocery stores, may be of little help.  They, too, are stretched thin. The Wall Street Journal reported food banks across the country are already straining under rising demand, and some worry there won’t be enough food to meet demand.

How Drug Prices Got So Bloated

Posted on by • Posted in Health Policy, Healthcare Reform, Hidden Fees, High Drug Prices, Optum Rx, Pharmaceutical Industry, Pharmacy Benefits Management, Profit, Profit Margin, Profit Model, Profit Motive, Shareholder Expectations, UnitedHealthcare, Wall Street • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/how-drug-prices-got-so-bloated?utm_source=post-email-title&publication_id=255152&post_id=169171522&utm_campaign=email-post-title&isFreemail=true&token=eyJ1c2VyX2lkIjo4ODU1Nzg5LCJwb3N0X2lkIjoxNjkxNzE1MjIsImlhdCI6MTc1MzQ0OTUxNiwiZXhwIjoxNzU2MDQxNTE2LCJpc3MiOiJwdWItMjU1MTUyIiwic3ViIjoicG9zdC1yZWFjdGlvbiJ9.duxGPDH1QMjULHWG9_pg6FQdsvj19UocpbArG67oe7Q&r=59t65&triedRedirect=true&utm_medium=email

It’s no secret the brand name prescription drug costs are high. The rising costs have been blamed by health care analysts on kickbacks within the drug supply chain demanded by the federal government, drug distributors (wholesalers), health insurance companies and pharmacy benefit managers (PBMs).

This month we got a look at just how bloated brand-name drug prices have become in the United States thanks to an analysis from the Drug Channels Institute (DCI).

How about $356 billion worth of pure glut in the prescription drug supply chain, according to the analysis by DCI. Simply put, the market price established for these drugs by manufacturers has $356 billion worth of markups that mainly accommodate the financial demands (i.e. kickbacks or rebates) of groups that profit off the prescription drug system in the United States, health insurers and their PBMs in particular.

 And that’s an all-time record.

Why?

Get ready to choke on your popcorn.

In the 1990s the federal government mandated in the Medicaid program that drug manufacturers offer a minimum rebate of 23% off the purchase price of brand name drugs. The feds also mandated that if drug manufacturers offer a better rebate on those drugs to someone else, the government also gets that same rebate.

The thought was no one gets a better deal than the federal government.

Medicaid then began to expand in the 2000s and the rebates and the demands increased.

Rebates expanded again as PBMs continued to gain more control over the drug supply chain. The PBMs now force drug manufacturers to offer significant concessions in order to get on the list of approved medications – known as a formulary – available to patients with health insurance.  

To account for these demands, drug manufacturers set the list price for their brand name drugs with these price concessions baked into the number.

DCI’s analysis found that baking is $356 billion of goodies for health care companies paid for by the government and you.

It’s the same kind of concept as a U.S. popular clothing retailer that displays inflated retail costs on the tags of goods and then right below displaying a lower “sale” price to make the consumer think they got a deal.

Here’s another way of thinking of it: Just like Congress has a lot of “pork” in its spending bills, there’s also a lot of pork in prescription drug costs that have very little to do with anything, other than increase profits for the health care industry.

Though the federal government intended to create a better system for taxpayers back in the 1990s when it demanded rebates in the Medicaid system, it instead created a feeding frenzy for companies in the drug supply chain.

In the year 2000 just a handful of companies in the drug supply chain dotted the Fortune 100 list of most financially successful companies. Today there are four such companies in the top 10.

The Minnesota-based health care conglomerate UnitedHealth leads that pack. The company’s profits have soared in the last two decades largely due to increasing medical costs and prescription drug costs paid by Americans. It has leaped over companies like Exxon Mobile and Apple to become the third largest company in America. Only Walmart and Amazon take in more revenue.

The company employs more than 400,000, including doctors and clinicians and has its own pharmacy benefits manager called Optum Rx.

We reported last month that Americans spent $464 billion last year on prescription drugs. That was also an all-time record, which will likely be set again and again and again until reforms are enacted.

How Health Insurance Monopolies Affect Your Care

Posted on by • Posted in Competition, Competition on Price, Competitive Bidding, Health Insurance Denial, Health Insurance Industry, Health Insurance Pre Authorization, Market Consolidation, Market Failure, Market Power, Market Share, Monopoly, Monopoly Behavior, Profit, Profit Margin, Profit Model, Profit Motive • Tagged , , , , • Leave a comment
https://time.com/7302346/health-insurance-monopolies-patient-care/?utm_source=beehiiv&utm_medium=email&utm_campaign=newsletter-health-matters&_bhlid=b8ef51635479257a1d1d099c9581345a28c94b91

Not long ago, Dr. Richard Menger, a neurosurgeon, was ready to operate on a 16-year-old with complex scoliosis. A team of doctors had spent months preparing for the surgery, consulting orthopedists and cardiologists, even printing a 3D model of the teen’s spine.

The surgery was scheduled for a Friday when Menger got the news: the teen’s insurer, Blue Cross Blue Shield of Alabama, had denied coverage of the surgery. 

It wasn’t particularly surprising to Menger, who has been practicing in Alabama since 2019. Alabama essentially has one private insurer, Blue Cross Blue Shield of Alabama, which has a whopping 94% of the market of large-group insurance plans, according to the health policy nonprofit KFF. That dominance allows the insurer to consistently deny claims, many doctors say, charge people more for coverage, and pay lower rates to doctors and hospitals than they would in other states.

“It makes the natural problems for insurance that much more magnified because there’s no market competition or choice,” says Menger, who in 2023 wrote an op-ed in 1819 News, a local news site, arguing that ending Blue Cross Blue Shield of Alabama’s health insurance monopoly would make people in the state healthier.

Blue Cross Blue Shield of Alabama also has the largest share of individual insurance plans in the state, according to data from the Centers for Medicaid & Medicare Services. Perhaps not coincidentally, Alabama also had the highest denial rates for in-network claims by insurers on the individual marketplace in 2023, according to a KFF analysis: 34%. Neighboring Mississippi, where the majority insurer has less of the market share at 81%, has an average denial rate of 15%.

Alabama is an extreme case, but people in many other states face health insurance monopolies, too. One insurer, Premera Blue Cross Group, has a 94% share of the large-group market in Alaska, and Blue Cross Blue Shield of Wyoming has a 91% market share in that state. In 18 states, one insurer has 75% or more of the large-group health insurance marketplace, according to KFF data.

These monopolies drive up costs, says Leemore Dafny, a professor at Harvard Business School and Harvard Kennedy School who has long studied competition among health insurance companies and providers.

“More competitors tend to drive lower premiums and more generous benefits for consumers,” she says. “There’s a lot of concern from analysts like myself about concentration in a range of sectors, including health insurance.”

Bruce A. Scott, the immediate past president of the American Medical Association, has said that when the dominant insurer in his state of Kentucky was renegotiating its contract with his medical group, it offered lower rates than it had paid six years before. “This same type of financial squeeze play is found nationwide, and its frequency has been exacerbated by health insurance industry consolidation,” he wrote in The Hill in 2023.

What happened to competition? There used to be a lot more regional health insurers, Dafny says. But as costs started to rise, they didn’t have enough leverage to negotiate prices down with providers and stay profitable. As a result, many were happy to be acquired by larger companies. Then hospitals and doctor’s offices merged to get more leverage against the bigger insurers. Now, there’s a lot of concentration among both provider groups and insurers.

“None of this had anything to do with taking better care of patients,” she says. “It had to do with trying to get the upper hand.” 

In a statement to TIME, Blue Cross Blue Shield of Alabama said that it was working to make the prior authorization process more transparent and reverse the requirement of prior authorization for certain in-network medical services. It will attempt to answer at least 80% of requests for prior authorization in near real-time by 2027, it says. (A coalition of major health insurers recently vowed to fix their prior authorization processes under pressure from the federal government.)

The insurer also says it welcomes competition. “We know Alabamians have a choice when it comes to choosing their health insurance carrier and we don’t take that for granted,” a spokesperson said in the statement. In the commercial and underwritten market—which represents the bulk of its business—Blue Cross Blue Shield Alabama competes with four other companies that sell individual, family, and group plans, the company says, and it competes with 68 companies who sell Medicare plans in Alabama. Its success in the state is partly because it sells policies in every county in Alabama, the insurer says, while others do not. 

Other casualties of such a concentrated health-insurance marketplace are rural hospitals and providers. Small rural hospitals are often independent and have not merged with other systems like many of their large urban counterparts, so they have an even harder time negotiating with the one big insurer in the state, says Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, a national policy center that studies health-care costs. That means big insurers will often refuse to cover procedures or pay lower prices for services.

“I’ve had rural hospitals tell me they can’t even get the health plan on the phone,” Miller says.

In the past decade, the Department of Justice has stopped some mergers, but has not been very aggressive at stopping consolidation in the health-care industry, Dafny says. That may be in part because the courts require a high standard of evidence to block a transaction, and the government might have been worried it would have lost whatever cases it brought.

A few factors prevent insurers with a monopoly from driving costs too high, says Benjamin Handel, an economics professor at the University of California, Berkeley who studies health care. One is a regulation called minimum loss ratio that essentially requires insurers to spend a certain share of what they earn from premiums on medical care. Another is that an insurer with a monopoly that angers consumers might attract attention from regulators, he says.

Of course, there’s not a whole lot regulators can do to make a marketplace more competitive. A state could try to incentivize more insurers to enter their states with tax breaks or other sweeteners, but it’s very hard to enter a market and offer low rates right away. The establishment of the health-care marketplaces in the Affordable Care Act allowed new entrants, Dafny says, but many of them did not survive.

Menger, the Alabama doctor, says that he and his colleagues—and therefore their patients—are basically stuck. His staff has to spend 10-15 hours a week negotiating with the insurer to get prior authorizations that sometimes don’t come, even while patients pay higher premiums. 

The teenage boy eventually got approved for the scoliosis surgery, but not after the family went through a lot of stress with postponements and uncertainty. “I think it’s pretty clear that the more competition, the better things are,” Menger says. “This prior authorization nonsense is really hurting patients.”

DOJ Questions UnitedHealth Doctors Re: Medicare Advantage Upcoding

Posted on by • Posted in Dept of Justice (DOJ), Health Insurance Industry, Medicare Advantage, Medicare Advantage Overpayments, Physician, Physician Diagnosis, Profit, Profit Margin, Profit Model, Profit Motive, UnitedHealthcare, Upcoding • Tagged , , , , • Leave a comment
https://healthcareuncovered.substack.com/p/doj-questions-unitedhealth-doctors?utm_source=post-email-title&publication_id=255152&post_id=167915638&utm_campaign=email-post-title&isFreemail=true&r=59t65&triedRedirect=true&utm_medium=email

I’ve been at this for so long and have seen so much. And it’s hard to overstate how significant the latest revelations from The Wall Street Journal are. According to its reporting, the U.S. Department of Justice’s criminal health care-fraud unit is questioning former UnitedHealth Group employees about the company’s Medicare billing practices regarding how the company records diagnoses that trigger higher payments from taxpayers.

For years, independent policy experts and *some* regulators have warned that the private Medicare Advantage program has become a breeding ground for upcoding and tax dollar waste. The tactic being scrutinized by the DOJ is called “upcoding.” Essentially, Medicare Advantage companies have an incentive to “find” new illnesses — even among patients who might not need additional treatment because the more serious the diagnoses, the bigger the government payouts to the company.

According to the Journal, prosecutors, FBI agents, and the Health and Human Services Inspector General have been asking ex-employees about special training for doctors, software that flags profitable conditions, and even bonuses for physicians who recode patient files. One former UnitedHealth doctor told the Journal that prosecutors inquired about pressure to use certain diagnosis codes and bonus pay for certain health care decisions that financially favored UnitedHealth. 

The Journal’s data shows that UnitedHealth’s members received certain lucrative diagnoses at higher rates than patients in other Medicare Advantage plans — billions of extra dollars that ultimately come from taxpayers. In one example, they reportedly pulled in about $2,700 more taxpayer dollars per patient visit when nurses went into seniors’ homes to hunt for additional conditions.

In a statement, UnitedHealth insists they “remain focused on what matters most: delivering better outcomes, more benefits, and lower costs for the people we serve.”

This latest criminal investigation joins at least two other DOJ probes into UnitedHealth’s billing and potential antitrust violations. And it’s yet another reminder that the Medicare Advantage program — which, much to many advocates alarm, now covers more than half of all Medicare enrollees – is desperately in need of real oversight.

If there’s any silver lining, it’s that courageous former employees are speaking up. They know what I know: This “profit-maximizing” through “upcoding” and “favorable selection” drains billions that could be better spent on actual patient care and pad Wall Street profits.

Gut Punches for Healthcare and Hospitals

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Center for Medicare and Medicaid Services (CMS), Deferred Healthcare, Financially Distressed, Health Insurance Coverage Adequacy, Health Policy, Health System, Healthcare Industry, Hospital, Hospital Industry, Medicaid Cuts, Medical Debt, Out of Pocket Expenses, Politics, Profit, Profit Margin, Profit Model, Profit Motive, Public Opinion, Public Perception, Shareholder Expectations, Sign of the Times, Underinsured, Uninsured, Wall Street • Tagged , , , , • Leave a comment
Gut Punches for Healthcare and Hospitals: The One Big Beautiful Bill Act and the CMS Proposed Rule

The healthcare industry is still licking its wounds from $1 trillion in federal funding cuts included in the One Big Beautiful Bill Act (OBBBA) signed into law July 4.

Adding insult to injury, the Center for Medicare and Medicaid services issued a 913-page proposed rule last Tuesday that includes unwelcome changes especially troublesome for hospitals i.e. adoption of site neutral payments, expansion of hospital price transparency requirements, reduction of inpatient-only services, acceleration of hospital 340B discount repayment obligations and more.

The combination of the two is bad news for healthcare overall and hospitals especially: the timing is precarious:

  • Economic uncertainty: Economists believe a recession is less likely but uncertainty about tariffs, fear about rising inflation, labor market volatility a housing market slowdown and speculation about interest rates have capital markets anxious. Healthcare is capital intense: the impact of the two in tandem with economic uncertainty is unsettling.
  • Consumer spending fragility: Consumer spending is holding steady for the time being but housing equity values are dropping, rents are increasing, student loan obligations suspended during Covid are now re-activated, prices for hospital and physicians are increasing faster than other necessities and inflation ticked up slightly last month. Consumer out-of-pocket spending for healthcare products and services is directly impacted by purchases in every category.
  • Heightened payer pressures: Insurers and employers are expecting double-digit increases for premiums and health benefits next year blaming their higher costs on hospitals and drugs, OBBBA-induced insurance coverage lapses and systemic lack of cost-accountability. For insurers, already reeling from 2023-2024 financial reversals, forecasts are dire. Payers will heighten pressure on healthcare providers—especially hospitals and specialists—as a result.

Why healthcare appears to have borne the brunt of the funding cuts in the OBBBA is speculative: 

Might a case have been made for cuts in other departments? Might healthcare programs other than Medicaid have been ripe for “waste, fraud and abuse” driven cuts? Might technology-driven administrative costs reductions across the expanse of federal and state government been more effective than DOGE- blunt experimentation?

Healthcare is 18% of the GDP and 28% of total federal spending: that leaves room for cuts in other industries.

Why hospitals, along with nursing homes and public health programs, are likely to bear the lion’s share of OBBBA’ cut fallout and CMS’ proposed rule disruptions is equally vexing.  Might the high-profile successes of some not-for-profit hospital operators have drawn attention? Might Congress have been attentive to IRS Form 990 filings for NFP operators and quarterly earnings of investor-owned systems and assume hospital finances are OK? Might advocacy efforts to maintain the status quo with facility fees, 340B drug discounts, executive compensation et al been overshadowed by concerns about consolidation-induced cost increases and disregard for affordability? Hospital emergency rooms in rural and urban communities, nursing homes, public health programs and many physicians will be adversely impacted by the OBBBA cuts: the impact will vary by state. What’s not clear is how much.

My take:

Having read both the OBBBA and CMS proposed rules and observed reactions from industry, two things are clear to me:

The antipathy toward the healthcare industry among the public  and in Congress played a key role in passage of the OBBBA and regulatory changes likely to follow. 

Polls show three-fourths of likely voters want to see transformational change to healthcare and two-thirds think the industry is more concerned with its profit over their care: these views lend to hostile regulatory changes. The public and the majority of elected officials think the industry prioritizes protection of the status quo over obligations to serve communities and the greater good.

The result: winners and losers in each sector, lack of continuity and interoperability, runaway costs and poor outcomes.

No sector in healthcare stands as the surrogate for the health and wellbeing of the population. There are well-intended players in each sector who seek the moral high ground for healthcare, but their boards and leaders put short-term sustainability above long-term systemness and purpose. That void needs to be filled.

The timing of these changes is predictably political. 

Most of the lower-cost initiatives in both the OBBBA changes and CMS proposals carry obligations to commence in 2026—in time for the November 2026 mid-term campaigns. Most of the results, including costs and savings, will not be known before 2028 or after. They’re geared toward voters inclined to think healthcare is systemically fraudulent, wasteful and self-serving.

And they’re just the start: officials across the Departments of Health and Human Services, Justice, Commerce, Labor and Veterans Affairs will add to the lists.

Buckle up.

Health Insurance as a Share of Median Income by U.S. State

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https://www.visualcapitalist.com/mapped-health-insurance-as-a-share-of-median-income-by-u-s-state/

Health Insurance as a Share of Median Income by U.S. State

This was originally posted on our Voronoi app. Download the app for free on iOS or Android and discover incredible data-driven charts from a variety of trusted sources.

Key Takeaways

  • Vermont tops the list, with insurance costing 19.6% of median income.
  • New Hampshire residents spend just 4% of their income on health insurance, the lowest in the nation.

Americans pay wildly different amounts for health insurance depending on where they live. This map shows which states pay the most (and least) when health insurance costs are measured as a share of median income.

The data for this visualization comes from WalletHub. It analyzed silver-tier health plan premiums in all 50 states and compared them to local median incomes to determine cost burdens.

Vermont and West Virginia Lead in Cost Burden

In Vermont, residents spend 19.6% of their monthly income on health insurance, the highest share in the country. West Virginia follows closely at 18.8%.

The South and Mountain West Feel the Pinch

Many Southern and Mountain West states, like Mississippi, Wyoming, and Louisiana, also rank high in insurance cost burden. These regions tend to have poorer health outcomes and lower median incomes, exacerbating affordability issues. As Brookings notes, Medicaid expansion status and rural demographics heavily influence insurance markets in these areas.

New Hampshire and the Northeast Are Least Burdened

New Hampshire residents spend just 4% of their income on health insurance, the lowest in the nation.

Massachusetts, Maryland, and Minnesota also enjoy low cost burdens. These states often have robust state-run exchanges, higher incomes, and broader Medicaid expansion, all of which help reduce costs.

GOP faces ‘big, beautiful’ blowback risk on ObamaCare subsidy cuts

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, ACA, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Out of Pocket Expenses, Uncompensated Care, Underinsured, Uninsured • Tagged , , , , • Leave a comment
GOP faces ‘big, beautiful’ blowback risk on ObamaCare subsidy cuts

Medicaid cuts have received the lion’s share of attention from critics of Republicans’ sweeping tax cuts legislation, but the GOP’s decision not to extend enhanced ObamaCare subsidies could have a much more immediate impact ahead of next year’s midterms. 

Extra subsidies put in place during the coronavirus pandemic are set to expire at the end of the year, and there are few signs Republicans are interested in tackling the issue at all. 

To date, only Sens. Lisa Murkowski (R-Alaska) and Thom Tillis (R-N.C.) have spoken publicly about wanting to extend them. 

The absence of an extension in the “big, beautiful bill” was especially notable given the sweeping changes the legislation makes to the health care system, and it gives Democrats an easy message: If Republicans in Congress let the subsidies expire at the end of the year, premiums will spike, and millions of people across the country could lose health insurance.  

In a statement released last month as the House was debating its version of the bill, House and Senate Democratic health leaders pointed out what they said was GOP hypocrisy. 

“Their bill extends hundreds of tax policies that expire at the end of the year. The omission of this policy will cause millions of Americans to lose their health insurance and will raise premiums on 24 million Americans,” wrote Senate Finance Committee ranking member Ron Wyden (D-Ore.), House Ways and Means Committee ranking member Richard Neal (D-Mass.) and House Energy and Commerce Committee ranking member Frank Pallone (D-N.J.). 

“The Republican failure to stop this premium spike is a policy choice, and it needs to be recognized as such.” 

More than 24 million Americans are enrolled in the insurance marketplace this year, and about 90 percent — more than 22 million people — are receiving enhanced subsidies.

“All of those folks will experience quite large out-of-pocket premium increases,” said Ellen Montz, who helped run the federal ObamaCare exchanges under the Biden administration and is now a managing director with Manatt Health. 

“When premiums become less affordable, you have this kind of self-fulfilling prophecy where the youngest and the healthiest people drop out of the marketplace, and then premiums become even less affordable in the next year,” Montz said. 

The subsidies have been an extremely important driver of ObamaCare enrollment. Experts say if they were to expire, those gains would be erased.  

According to the Congressional Budget Office (CBO), 4.2 million people are projected to lose insurance by 2034 if the subsidies aren’t renewed.  

Combined with changes to Medicaid in the new tax cut law, at least 17 million Americans could be uninsured in the next decade. 

The enhanced subsidies increase financial help to make health insurance plans more affordable. Eligible applicants can use the credit to lower insurance premium costs upfront or claim the tax break when filing their return.  

Premiums are expected to increase by more than 75 percent on average, with people in some states seeing their payments more than double, according to health research group KFF. 

Devon Trolley, executive director of Pennie, the Affordable Care Act (ACA) exchange in Pennsylvania, said she expects at least a 30 percent drop in enrollment if the subsidies expire. 

The state starts ramping up its open enrollment infrastructure in mid-August, she said, so time is running short for Congress to act. 

“The only vehicle left for funding the tax credits, if they were to extend them, would be the government funding bill with a deadline of September 30, which we really see as the last possible chance for Congress to do anything,” Trolley said. 

Trolley said three-quarters of enrollees in the state’s exchange have never purchased coverage without the enhanced tax credits in place.  

“They don’t know sort of a prior life of when the coverage was 82 percent more expensive. And we are very concerned this is going to come as a huge sticker shock to people, and that is going to significantly erode enrollment,” Trolley said.  

The enhanced subsidies were first put into effect during the height of the coronavirus pandemic as part of former President Biden’s 2021 economic recovery law and then extended as part of the Inflation Reduction Act. 

The CBO said permanently extending the subsidies would cost $358 billion over the next 10 years. 

Republicans have balked at the cost. They argue the credits hide the true cost of the health law and subsidize Americans who don’t need the help. They also argue the subsidies have been a driver of fraudulent enrollment by unscrupulous brokers seeking high commissions. 

Sen. Bill Cassidy (R-La.), chair of the Senate Health, Education, Labor and Pensions Committee, last year said Congress should reject extending the subsidies. 

The Republican Study Committee’s 2025 fiscal budget said the subsidies “only perpetuate a never-ending cycle of rising premiums and federal bailouts — with taxpayers forced to foot the bill.” 

But since 2020, enrollment in the Affordable Care Act marketplace has grown faster in the states won by President Trump in 2024, primarily rural Southern red states that haven’t expanded Medicaid. Explaining to millions of Americans why their health insurance premiums are suddenly too expensive for them to afford could be politically unpopular for Republicans.

According to a recent KFF survey, 45 percent of Americans who buy their own health insurance through the ACA exchanges identify as Republican or lean Republican. Three in 10 said they identify as “Make America Great Again” supporters. 

“So much of that growth has just been a handful of Southern red states … Texas, Florida, Georgia, the Carolinas,” said Cynthia Cox, vice president at KFF and director of the firm’s ACA program. “That’s where I think we’re going to see a lot more people being uninsured.” 

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.

Congress Could Force Patients in Rural America To Make Dire Medical Care Choices

Posted on by • Posted in 2026 Mid Term Election Issues, 2028 Election Issues, Bankruptcy, Financial Distress, Financial Instability, Financial Stewardship, Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicaid, Medicaid Cuts, Rural Health, Rural Hospital, Uncompensated Care, Underinsured, Uninsured • Tagged , , , , • Leave a comment
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New Medicaid funding rules proposed by Congress this week would halt efforts at the state level to better fund rural hospitals and deliver services to the most vulnerable populations in those areas. You can be certain that the administrators and staff of those hospitals, as well as leaders of the communities they serve, are watching closely to see if the cuts are enacted. 

Lawmakers at the federal level are trying to make deeper cuts to Medicaid spending in an effort to lower the amount of deficit spending that would be created by President Trump’s spending plan. Trump has dubbed the plan his “big beautiful bill.” 

Feds Would Strip Rural Hospitals of Lifeline Funds

Republican members of the Senate Finance Committee this week released their version of the bill that would drain funding for rural hospitals, which rely heavily on Medicaid funds to treat patients. It’s estimated that 25 to 40 percent of services provided by such hospitals are funded by Medicaid.

The federal government and states share the up-front medical costs for Medicaid patients. The federal government then reimburses states up to 50 percent of their Medicaid spending every year.

Many states fund their portion of the cost by taxing entities that provide those services to Medicaid patients.

The latest proposal in Congress would not only restrict how many patients could receive benefits, but it would also stop states from implementing those provider tax programs to help fund Medicaid services provided to residents.

At the federal level, the thinking is that if states keep taxing providers to fund Medicaid services, then the federal government will have to keep reimbursing states a portion of those costs. 

The downside to that is many experts, along with several Republicans in Congress, namely Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and Josh Hawley of Missouri, have predicted it will decimate rural hospitals.

West Virginia Republican Sen. Jim Justice went a step further, saying that the plan to limit states’ use of provider taxes will “really hurt a lot of folks.” Despite that statement, Justice said he is OK with the freeze.

State Lawmakers Sound the Alarm

There are 39 states with at least three or more provider taxes used to help fund Medicaid services. Alaska is the only state with no such tax.

Some states, such as Ohio, have set up a new rural hospital fund using provider taxes to help rural hospitals deliver Medicaid services to patients.

Ohio Governor Mike DeWine and the Republican-led state legislature set up a pilot program called the Rural Ohio Hospital Tax Pilot Program. The measure would allow counties to levy a tax on their local hospitals that would then be used to fund Medicaid services.

DeWine said the pilot program would help ease the financial stress rural hospitals face in Ohio. The plan contained in Ohio House Bill 96 has the blessing of the Ohio Hospital Association.

That state fund reportedly would be neutered by the federal proposal. Ohio has at least three different provider taxes.  

A group of Republican state lawmakers recently sent a letter to their federal counterparts pleading with them to remove the bill language because it would “torpedo” plans to keep rural hospitals functioning.

The American Hospital Association, a 130-year-old trade group of more than 5,000 hospitals and health care providers, this month released the impact on rural hospitals if this plan went into effect.

 More than $50 billion would be lost by 2034, and more than 1.8 million rural Americans would lose health benefits.

Kentucky residents would be impacted the most, with 143,000 losing benefits, followed by 135,000 Californians. More than 86,000 Ohioans would lose Medicaid coverage under the plan by 2034, making it the third most impacted state.

To blunt the effects of the cuts, Collins reportedly is proposing the establishment of a $100 billion relief fund that could provide financial support to affected providers, rural hospitals in particular. Whether that or a similar but smaller fund will wind up in the final draft of the legislation apparently will be decided this weekend. Meanwhile, the Senate parliamentarian has ruled against many of the provisions of the Senate version of the bill, including the Finance Committee’s provider tax framework, which puts the whole thing in flux.

Senate leaders say they plan a long series of votes on amendments of the bill on Sunday. The “vote-arama” likely will go on throughout Sunday night and into Monday. If the Senate does pass its version of the bill, it will have to go back to the House. Lawmakers are under a self-imposed deadline to get the legislation to Trump by the July 4 holiday.