More than 80 of his customers who were enrolled in the same Medicare supplemental plan from the insurer Chubb got hit last August with a 45% increase.
“In my 49 years of doing biz as a broker, I’ve never seen a premium increase be effective immediately on everyone, instead of on their policy anniversary,” said Jaggi, whose brokerage scrambled to find more affordable options for clients. The policies pick up deductibles and other costs not covered in traditional Medicare, and without one there is no upper limit on how much a consumer might owe each year.
While 45% was an unusually big jump, Jaggi and other brokers say double-digit premium increases for Medicare supplemental, or Medigap, policies are becoming the norm.
A Chubb spokesperson did not respond to requests for comment on the increase.
More than 12 million people — of those in traditional Medicare — buy a Medigap policy. Others rely on some sort of retiree employer coverage or a different backup. About 13% of people in traditional Medicare don’t have supplemental coverage, according to Â鶹ŮÓÅ, meaning they could be vulnerable to large costs if they have a serious illness.
In the supplemental market, following big increases last year, rates appear to be rising again. In early 2026 filings with state insurance commissioners from Aetna, Blue Cross Blue Shield, Cigna, Humana, Mutual of Omaha, and UnitedHealthcare, rate increases for Plan G policies — the most commonly purchased supplement type — ranged from just in the first quarter, according to Nebraska-based consulting firm Telos Actuarial.
“While this is a small dataset across a select number of states, it’s an indication that carriers are looking to correct their premium rates in light of upward pressure on their claims experience,” said Brett Mushett, a consulting actuary with Telos.
Climbing Numbers
Premium rates vary based on the type of coverage chosen, where a beneficiary lives, and their age. For Plan G coverage, beneficiaries paid an in 2023, according to Â鶹ŮÓÅ. That amount has likely risen since.
“In some states, like Ohio, Medicare supplements for years would have a 3% to 5% year-over-year increase. Now it’s 10% to 15%,” said Amanda Brewton, owner of Medicare Answers Now, a marketing organization whose clients are sales agents.
In Alaska, Premera Blue Cross raised the premiums on its Plan G policies by nearly 12% for this year, according to rate sheets provided to Â鶹ŮÓÅ Health News by insurance agent Patricia Mack, who said another insurer raised rates by nearly 13%.
For example, a 65-year-old woman who last year would have been charged $172 a month for a Plan G policy would now face a monthly rate of $192, said Mack, who owns Alaska Insurance Benefits in Wasilla.
Premera spokesperson Courtney Wallace said in an email that Medicare makes changes to deductible and copayment rates each year, which affects supplemental plans that cover those increasing amounts.
Wallace also noted that the insurer saw higher medical service use among its members, “which further drove claims costs and ultimately impacted premiums.”
Agents and policy experts blame a range of factors for rising premiums: an increase in the use of medical services by beneficiaries; the aging of the population; increases in labor and medical costs; rules in some states governing Medigap plans; and people’s enrolling in — or getting out of — private Medicare Advantage plans.
“Five years ago, it was exceedingly uncommon to have a carrier with a rate increase of more than 10%. Now it’s very uncommon to see a rate increase below 10%, and it’s not uncommon to see it over 20%,” said Chalen Jackson, vice president for government affairs at Integrity, a Dallas-based company that sells life and health insurance.
Jaggi, who co-owns Jaggi Petry Insurance & Investments in Forsyth, Illinois, along with his daughter, said he eventually found other options for many of those 80-plus clients with the large increase, which came from an insurer that had previously been the lowest-cost option. But it wasn’t easy — and continuing increases are expected.
“These are unbelievable increases,” said Jaggi, who said he is seeing premium hikes exceeding 15% this year across a range of insurers.
Policy experts have outlined possible solutions, including for Congress to cap out-of-pocket costs for Medicare beneficiaries or subsidize the purchase of Medigap coverage.
“Traditional Medicare is the only federal health insurance program without an out-of-pocket cap,” Sen. Ron Wyden (D-Ore.) wrote in an email, adding that the program “needs to be updated and strengthened to protect the Medicare guarantee for American seniors.”
But making changes to Medicare that require congressional approval is unlikely in the current legislative environment, especially because adding an out-of-pocket cap would add costs to the federal budget.
How This Plays Out
People generally qualify for Medicare when they turn 65. Beneficiaries after they initially enroll in the traditional fee-for-service program to purchase a Medigap plan at standard rates without having to answer health-related questions.
Strict rules then kick in around when beneficiaries can enroll in or switch Medigap coverage and options become much more limited, with each one generally involving trade-offs or tough choices.
have what’s known as a “birthday rule,” which requires insurers once a year to allow people enrolled in a Medigap plan to change to different supplemental coverage — usually around their birthdays — without being medically underwritten. Those rules can help consumers, including those with health conditions, to switch.
An additional — Connecticut, Massachusetts, Maine, and New York — require insurers to offer at least one Medigap policy to all applicants either year-round or during an annual enrollment period, depending on the state. Changes are allowed no matter the person’s health.
Another option for those facing high Medigap costs is to leave traditional Medicare and enroll in a private-sector Medicare Advantage plan, which have out-of-pocket caps. But joining one means beneficiaries must generally rely on a set of in-network doctors and hospitals. And if they change their mind and want to go back to traditional Medicare, they have only a 12-month window in which to purchase a Medigap plan without passing health questions. After that, it can be more difficult.
“A lot of people don’t know that if they are in Medicare Advantage for a year, they can get turned down by a Medigap plan or charged really high premiums because of a preexisting condition, which for many people effectively traps them in MA plans,” said , a research associate at the liberal Center for American Progress and co-author of a on the issue.
There are some exceptions. For example, if a Medicare Advantage plan withdraws from a market or leaves the Medicare program, its enrollees can qualify for a supplemental plan without being asked health questions or charged more for having preexisting conditions.
For this year alone, about 2.6 million people when their insurer pulled out of their markets, according to Â鶹ŮÓÅ, and more than a million lost coverage for 2025. Many switched to other MA plans, but “somewhere around 440,000 of those people did go to a Medicare supplement policy,” sometimes because there was no other MA plan in their area, said George Dippel, president of Deft Research, a Minneapolis-based market research organization focused on insurance for older people. Deft is part of Integrity, the Dallas company.
Some Medicare experts note that anytime insurers enroll people whose health status they can’t consider — whether because of birthday rules or because their Medicare Advantage plan left the market and thus qualified them for an exemption from medical underwriting — it potentially exposes them to more health care utilization and higher costs, making them more likely to increase premiums across the board to offset the possible financial hit.
Another option mentioned by brokers for people looking to lower their costs is to consider one of the two types of Medigap plans that come with a deductible, which is currently just under $3,000 for a year. Those plans charge far lower monthly premiums than Medigap plans that pick up a much larger portion of annual amounts people must pay toward their Medicare services.
Still, “a lot of people are not comfortable with a $3,000 deductible,” Mack said.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/medicare/medigap-medicare-advantage-premiums-rate-increase-few-alternatives/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2228699&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>But there’s a catch: If people want to move to original Medicare and buy a supplemental Medigap insurance plan to cover some out-of-pocket costs, they may not be able to. Medigap insurers can generally refuse coverage to applicants whose medical history or current health problems might make them expensive to cover, a process called medical underwriting.
“We really want people to factor that in,” said , managing policy attorney at the Center for Medicare Advocacy. “If someone is in a Medicare Advantage plan for several years and then wants to switch to original Medicare, they may find they can’t switch and also get a Medigap plan.”
There are many reasons people might want to trade their MA plan for traditional Medicare. Although MA managed-care plans are typically cheaper and offer benefits not available in original Medicare, such as coverage for vision and hearing services, they have smaller provider networks than the original program and, sometimes, extensive prior authorization requirements.
In addition, as Medicare Advantage plan in recent years, a growing number of plans are pulling out of areas they used to serve, leaving members with fewer options. This year, an estimated 1 in 10 MA plan members will be forced out of their plans for this reason, according to a in February.
“We saw some Medicare Advantage plans that just left the market completely and stopped issuing plans,” said Emily Whicheloe, education director at the Medicare Rights Center.
For those considering a switch to original Medicare, getting a Medigap plan can be tricky. Federal law provides a one-time, for people 65 or older and newly covered by Medicare Part B to sign up for any Medigap plan without underwriting. After that initial sign-up period ends, however, there are fewer coverage guarantees.
But some do exist. Here are a few key circumstances and time frames when people are guaranteed a Medigap plan without having to undergo underwriting:
- People who live in Connecticut, Massachusetts, or New York can sign up for a Medigap policy without underwriting. In Maine, there is a one-month window each year when Medigap insurers must offer Plan A to all comers without underwriting. (Plan A provides less comprehensive coverage than some of the other standardized plan types.)
- People who sign up for a Medicare Advantage plan when they are first eligible for Medicare Part A at age 65 can switch to original Medicare within the first year and buy a Medigap plan too. This is sometimes called the “.”
- If a Medicare Advantage plan leaves Medicare or in an area, affected enrollees can switch to original Medicare and buy a Medigap plan either 60 days before or up to 63 days after their MA coverage ends. During this special enrollment period, they can’t be turned down or charged more based on their health.
- If an individual and no longer has access to their Medicare Advantage plan providers, they can switch to original Medicare and apply for a Medigap policy either 60 days before or up to 63 days after their MA coverage ends. That typically happens when someone notifies the plan of their permanent move or the plan discovers it, said , a training, policy, and technical assistance consultant at California Health Advocates who specializes in Medicare and Medigap coverage.
There are other circumstances when someone might qualify for a special enrollment period under federal rules, and states may have additional qualifying events that are more generous than federal standards.
Patient advocates emphasize that it’s often useful to work with a counselor at the , or SHIP, for free, unbiased help figuring out Medigap coverage options. SHIP counselors can help applicants identify potential avenues to qualify for Medigap coverage without underwriting at both the federal and state levels.
People who don’t qualify for a guaranteed right to a Medigap plan without underwriting may still be approved for coverage. Premiums may be higher, however, and plans may impose a waiting period of up to six months for coverage of preexisting medical conditions in certain circumstances.
Beware: More Underwriting
In recent years, some Medigap insurers have spent a growing percentage of premiums on medical claims, putting pressure on profits, Burns said. “Medigap insurers’ underwriting has tightened up considerably recently,” she said.
The list of health conditions that Medigap insurers might deny coverage for is long, including Alzheimer’s disease, asthma, cancer, congestive heart disease, diabetes with complications, end-stage renal disease, high blood pressure, and stroke, among others, according to a of leading insurers’ applications.
When people apply for a Medigap plan that will be medically underwritten, they will typically be asked to fill out a health questionnaire, said , a principal and consulting actuary at Milliman who is a Society of Actuaries fellow. Increasingly, insurers are requesting that people agree to a prescription drug background check, Ortner said.
“Oftentimes, that prescription drug history may be the primary driver of a decision as it relates to underwriting,” he said, rather than a physical exam or medical records review.
Insurers don’t all have the same underwriting rules, however. Here again, a SHIP counselor may be useful for pointing people to specific companies that accept applicants with a particular medical diagnosis, or have different waiting periods or coverage exclusions.
“They have access to a Medigap comparison tool in addition to what is existing on that can give you a very good estimate of what you may pay for those Medigap plans,” said , associate director of health coverage and benefits at the National Council on Aging.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/medicare/medicare-open-enrollment-pitfalls-switching-from-advantage-original-medigap/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2165325&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called , a data analysis by Â鶹ŮÓÅ Health News has found.
The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”
“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.
There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.
Medicare Advantage plans offer seniors a private alternative to original Medicare. The insurance plans enroll about members, more than half the people eligible for Medicare.
CMS is set to announce a final rate decision by early next month. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views. As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.
Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 published comments as of March 12.
Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.
“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/insurance/the-week-in-brief-medicare-advantage-payments-dark-money/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2168915&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>Yet about 82% of the comments are identical to a letter that appeared on the website of a secretive advocacy group called Medicare Advantage Majority, a data analysis by Â鶹ŮÓÅ Health News has found.
The “” group does not reveal its funders or much else — other than to say it is “dedicated to protecting and strengthening Medicare Advantage” and is “powered by hundreds of thousands of local advocates nationwide.”
“Our campaign provides information and offers tools for concerned Americans to use to reach decision makers,” spokesperson Darren Grubb said in an email. The group has spent more than $3.1 million on hundreds of Facebook ads since September 2024, according to , a database of the social media company’s online ads.
There’s no doubt health insurers are unhappy with a from the Centers for Medicare & Medicaid Services, or CMS, to keep Medicare Advantage reimbursement rates essentially flat in 2027 — far less than they expected from the Trump administration.
Medicare Advantage plans differ from traditional Medicare because private insurance companies administer them. The insurance plans enroll about members, more than half the people eligible for Medicare. The plans offer things like vision and drug coverage, but Medicare Advantage insurers restrict the hospitals and doctors that patients can use and require prior approval for various procedures.
CMS is set to announce a final decision by early next month on the rate proposal. The agency solicited on the proposal from Jan. 26 through Feb. 25 to give interested parties and the public a chance to air their views.
Medicare Advantage Majority, which says the rate proposal amounts to a “cut” in services and warns of dire consequences for seniors should it go through, accounted for at least 13,522 of the 16,422 comments published as of March 12.
The proposed rate plan “puts my access to care at risk,” the group’s template letter to policymakers reads in part. “If the investment made by Washington in the Medicare Advantage program is nearly flat year-over-year, I could lose benefits I rely on every day, including affordable prescriptions, capped out of pocket costs, and access to trusted doctors and specialists.”
“Medicare Advantage is not optional for me. The cost protections alone have saved me thousands of dollars and made my health care manageable. Without this program, I would face higher costs, fewer providers, and fewer benefits at a time when I can least afford it,” the letter states.
Critics warn that these sorts of campaigns may create a misleading impression of grassroots support, especially when it’s not clear who is financing them.
“It puts a different spin on a massive groundswell of comments to know all are being driven by one specific organization,” said Michael Beckel, director of money in politics reform for Issue One, a group that seeks to limit the influence of money on government policy and legislation.
“There’s no way for the public to know what wealthy donors or special interests are funding dark money groups like this,” he said. “That means there’s no scrutiny of who’s really calling the shots.”
Some health care policy experts, who have long argued that the government overpays Medicare Advantage plans by tens of billions of dollars every year, believe industry groups or their surrogates routinely overstate possible negative impacts of rate decisions they don’t like.
“The plans always say that the sky is falling,” said Matthew Fiedler, a health care policy expert with the Brookings Institution. “The industry has a lot of money at stake here. They try to exert pressure on policymakers any way they can.”
At the same time, even critics concede that some of the millions of people enrolled in Medicare Advantage plans could face service cuts if insurance companies are not satisfied with government payments.
“It is legitimate for people to be worried,” said Julie Carter, counsel for federal policy at the Medicare Rights Center, a group that advocates for older adults and people with disabilities.
Her group argues that Medicare Advantage plans have never attained expected cost savings and instead have been overpaid for years at least partly due to “actions to maximize profits.” She said the health plans “are supposed to be saving money, not taking extra.”
People struggling to pay health care bills may have little use for the policy debate in Washington.
“If it wasn’t for being able to have this program, I really wouldn’t be able to afford any kind of medical services, to be honest,” said EsterAlicia Rose, 75, who works at the front desk of a hotel in Pagosa Springs, Colorado. She said she signed the Medicare Advantage Majority form letter to reach policymakers.
Kathy Lovely-Marshall, 66, a retired nurse who lives in Brookville, Ohio, did too. She said she receives “a lot of perks” from her plan, such as dental care, eyeglasses, and prescriptions.
“All those things are a big plus as far as I am concerned,” she said. “I’m very happy with the plan I have.”
But Corenia Branham, 90, a widow and cancer survivor who lives in Alum Creek, West Virginia, said she wants nothing to do with Medicare Advantage plans run by private health insurance companies. She said she didn’t turn in any of the four form letters under her name, which were posted online by CMS on Feb. 23 and signed, “Miss Corenia Branham Branham.” It’s not clear why her last name is signed twice.
Branham said she’s not on Medicare Advantage and doubts she could count on it for needed care.
“I wouldn’t recommend it to nobody,” she said. “I sure don’t want anything to do with it.”
Grubb, the Medicare Advantage Majority spokesperson, disputed that account. He said Branham responded to an ad on Facebook. On Feb. 6, she “completed the form with her information and chose to send her comment to CMS as well as to her representatives in Congress and the White House,” he said.
Other Medicare Advantage advocacy groups have stepped up ad campaigns as the rate decision looms.
The Better Medicare Alliance, whose “allies” include a range of health insurers, health care providers, and consumers, is urging seniors to “Tell Washington to Stand Up for Medicare Advantage.”
“We’ve mobilized beneficiaries to write letters and make phone calls, and we’ve run digital ads on streaming platforms,” spokesperson Susan Reilly said.
Reilly said that this year roughly 3 million seniors “were forced to find new coverage” because plans either shuttered operations or left some areas.
She also said Medicare Advantage plans have “scaled back” benefits such as offering transportation to medical appointments, nutrition support, and dental and vision coverage, while over the past two years beneficiaries have faced an average $900 increase in out-of-pocket maximums.
“We do view this as especially serious,” Reilly said. “This isn’t a single bad year; it’s the cumulative effect of years of underfunding and policy disruption from the previous administration that has left the program increasingly vulnerable.”
As of March 12, CMS said it had received 46,884 comments but had posted only 16,422 online.
CMS spokesperson Catherine Howden said the agency would make more comments public “as soon as practicable.”
“The agency focuses on reviewing the substance of timely submissions and does not speculate on volume, sentiment, or potential impact of comments while the comment period is open/under review,” she said in a statement.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/aging/medicare-advantage-rates-public-comments-industry-ads-facebook-dark-money/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2166409&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>
It’s been a tough week for Health and Human Services Secretary Robert F. Kennedy Jr. In addition to Kennedy having surgery to repair a torn rotator cuff, personnel issues continue to plague the department: The nominee to become surgeon general, an ally of Kennedy’s, may lack the votes for Senate confirmation. The controversial head of the Food and Drug Administration’s vaccine center will be resigning next month. And a new survey finds Americans have less trust in HHS leaders now than they did during the pandemic.
Meanwhile, the Trump administration continues its crackdown over claims of rampant health care fraud. In addition to targeting the Medicaid programs in states led by Democratic governors, the Centers for Medicare & Medicaid Services is also taking aim at previously sacrosanct Medicare Advantage plans.
This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Anna Edney of Bloomberg News, Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico Magazine, and Shefali Luthra of The 19th.
Panelists
Among the takeaways from this week’s episode:
- Americans feel more confident in career scientists at federal health agencies than in the agencies’ leaders, according to a new survey from the Annenberg Public Policy Center at the University of Pennsylvania. Yet the survey also sheds more light on the erosion of trust in public health officials and scientific research.
- The FDA’s vaccine chief, Vinay Prasad, is leaving — again. Prasad was a critic of the agency before he joined it, and his tenure has been shaped by the same attitude, affecting career officials’ morale and the agency’s interactions with outside companies.
- The Trump administration has extended its fraud crackdown campaign into Medicare Advantage plans. The privately run alternative to traditional Medicare coverage has been a GOP darling from the get-go. Yet President Donald Trump is nudging the party away from its pro-business stance on private insurance, arguing the government should give money to patients rather than insurers — a justification for policies undermining the Affordable Care Act.
- And Wyoming became the latest state to enact a six-week abortion ban, a move that’s being challenged in court. The development points to the fact that while federal policymaking on abortion has largely stalled, the issue is still very much in play in the states as abortion opponents keep pushing back on access to the procedure.
Also this week, Rovner interviews Andy Schneider of Georgetown University about the Trump administration’s crackdown on what it alleges is rampant Medicaid fraud in Democratic-led states.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: The Marshall Project’s “,” by Shannon Heffernan, Jesse Bogan, and Anna Flagg.
Anna Edney: The Wall Street Journal’s “,” by Christopher Weaver, Tom McGinty, and Anna Wilde Mathews.
Shefali Luthra: The New York Times’ “,” by Apoorva Mandavilli.
Joanne Kenen: The Idaho Capital Sun’s “,” by Laura Guido.
Also mentioned in this week’s podcast:
- The Annenberg Public Policy Center’s “.”
- Â鶹ŮÓÅ Health News’ “Six Federal Scientists Run Out by Trump Talk About the Work Left Undone,” by Rachana Pradhan and Katheryn Houghton.
- Bloomberg Law’s “,” by Sandhya Raman.
- The 19th’s “,” by Shefali Luthra.
- The Georgetown University McCourt School of Public Policy Center for Children and Families’ “,” by Andy Schneider.
Clarification: This page was updated at 5:10 p.m. ET on March 12, 2026, to clarify that Vinay Prasad, the FDA’s vaccine chief, will be leaving his job in April. In an email after publication, William Maloney, an HHS spokesperson, said Prasad is “leaving of his own accord.”
[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]
Julie Rovner: Hello from Â鶹ŮÓÅ Health News and WAMU public radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Â鶹ŮÓÅ Health News, and I’m joined by some of the best and smartest reporters covering Washington. We are taping this week on Thursday, March 12, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Shefali Luthra of the 19th.
Shefali Luthra: Hello.
Rovner: Anna Edney of Bloomberg News.
Anna Edney: Hi, everybody.
Rovner: And Joanne Kenen at the Johns Hopkins Bloomberg School of Public Health and Politico Magazine.
Joanne Kenen: Hi, everybody.
Rovner: Later in this episode, we’ll have my interview with Andy Schneider of Georgetown University, who will try to explain how the federal government’s fraud crackdown on blue-state Medicaid programs is something completely different from any fraud-fighting effort we’ve seen before. But first, this week’s news — and some of last week’s.
Let’s start at the Department of Health and Human Services, where I think it’s safe to say Secretary Robert F Kennedy Jr. is not having a great week. The secretary reportedly had to have his rotator cuff surgically repaired on Tuesday. It’s not clear if he injured it during one of his famous video workouts. But it is clear, at least according to from the University of Pennsylvania’s Annenberg Center, that the American public is not buying what he’s selling when it comes to policy. According to the survey, public trust in HHS agencies, which already took a dive during the pandemic, has fallen even more since Kennedy took over the department. Although, interestingly, public trust in career HHS officials is higher than it is for their political leaders. And trust in outside professional health organizations, places like the American Heart Association and the American Academy of Pediatrics, is higher than for any of the government entities.
Perhaps related to that is another piece of HHS news from this week. The FDA [Food and Drug Administration] approved a label change for the drug leucovorin, which Secretary Kennedy last fall very aggressively touted as a potential treatment for autism. But the drug wasn’t approved to treat autism. Rather, the label changes to treat a rare genetic condition. Kennedy bragged about leucovorin, by the way, at the same press conference that President [Donald] Trump urged pregnant women not to take Tylenol, which has not been shown to contribute to the rise in autism. Maybe it’s fair to say the public is paying attention to the news and that helps explain the results of this Annenberg Center survey?
Luthra: Maybe. I was just thinking, we do know that Tylenol prescriptions for people who are pregnant did go down, right? There’s research that shows, after that press conference, behaviors did change. And so to your point, it’s clear there is a lot of confusion, and confusion maybe breeds mistrust. But I don’t know that we can necessarily say that American voters and the public at large are very obviously informed as much as they are perhaps disenchanted by things that seem as if they were told would restore trust and make things clearer and in fact have not done so.
Rovner: That’s a fair assessment. Anna.
Edney: Yeah, I think there’s a lot of overpromising and underdelivering, and that can kind of create this issue where this administration — and RFK Jr. has been doing this as well — kind of is making these decisions from the top, rather than having these normal conversations with the career scientists and things like that, where the public can kind of follow along on why the scientific decisions are being made if they so choose to, or at least have an idea that there was a discussion out there. And that’s not happening. So that’s not something that’s creating a lot of trust. I think people are seeing that as unscientific and chaotic.
Rovner: I was particularly interested in one of the findings in the survey, is that Dr. Fauci, Dr. Tony Fauci, who was sort of the bête noire of the pandemic, has a higher approval rating than either RFK Jr. or some of his top deputies. Joanne, I see you nodding.
Kenen: Yeah that was so stri— I mean, it’s still not high. It was, I believe it was — I’m looking for my note — but I think was 54%, which is not great. But it was better than Dr. [Mehmet] Oz [head of the Centers for Medicare & Medicaid Services]. It was better than Kennedy. It was better than a bunch of people. So, but it also shows that half the country still doesn’t trust him. It was a really interesting survey, but the gaps in trust in credible science are still significant. What was interesting is the declining trust in our government officials in health care, but there’s still, nationally, the U.S. population, there’s still a lot of skepticism of science and public health. Maybe not as bad as it was, but still pretty bad.
Luthra: And Julie, you alluded to these famous push-up and workout videos. And part of what you’re getting at — right? — is that the communications that we see are targeted toward a not necessarily very large audience. It is these people who are hyper-online, in particular internet spaces and communities, and that’s somewhat divorced from most people and how they live their lives. And when you focus your message and you’re campaigning on this very particular slice, it’s just a lot easier to lose sight of where people are and what they want from their government and what they will actually appreciate.
Rovner: It’s true. The online America is very separate from the rest of America, which is a whole lot bigger. Well—
Kenen: And there’s also the young people who probably aren’t in these surveys who, teenagers, who are getting a lot of information on TikTok about supplements and raw milk. And the young men and the teenage boys and the supplements is a big deal, and that’s online. And also we have been seeing for a while, but I think it’s probably creeping up, the recommendations about psychedelics. So there’s all this stuff out there that isn’t going to be picked up by that poll. But yes, it was an interesting poll.
Rovner: All right. Well, meanwhile over at the Food and Drug Administration, in-again out-again in-again vaccine chief Vinay Prasad is apparently out again, or will be as of later this spring. I feel like Prasad’s very rocky tenure has been kind of a microcosm for the difficulties this administration has had working with career scientists at FDA and elsewhere, at HHS. Anna, what made him so controversial?
Edney: Well, I think, Prasad was an FDA critic before he came to the agency. And so essentially, when he was out in public, particularly during covid, but there were even criticisms he had before that. He was criticizing these career scientists at the agency. And so he got there, and the way he appeared to operate was that he knew best and he didn’t need to talk to any of these people that had been there, some for decades, and that was getting him in a lot of trouble. But he was being defended and protected by FDA Commissioner Martin Makary, and he really supported Prasad, and he called him a genius and wanted him to stay on. So the first time Prasad left, he convinced him to come back. And now this time, I think, things maybe just went a bridge too far when there was sort of this behind-the-scenes but very public fight with a company trying to make a rare-disease drug. And this is something that, particularly, several senators really, really hate, is when the FDA is getting in the way of a rare-disease drug getting to market, because they don’t think that that’s something the agency should be trying to do unless the drug is maybe wholly unsafe. But they think anyone should be able to try it. And so when this exploded and FDA officials were and HHS officials were behind the scenes, but very publicly, calling this company a liar, it was just a bridge too far.
Rovner: Well, and he, this was, this incredibly unusual in which he tried to not be quoted by name, but kind of hard when the head of the agency, or the head of the center at FDA is basically trashing a company, trying to do it on background. Was that kind of the last straw?
Edney: Yeah, I think so. And sort of an aside on that. I’m curious how that phone call even was allowed to be set up and called. Because, it’s not like he did it on his own. There were, there was an infrastructure around him that helped him set that up. So I’m curious about why that even went down, but I think that was definitely what pushed him out the door. You know, this company wanted to get this drug approved. The FDA had said, No, not unless you do this extremely difficult trial, which the company said would require drilling holes in people’s heads, for what they were trying to get approved, and that it would be a placebo, essentially, for some of those patients, even when you get a hole drilled in your head, and this could be a 10-hour sham surgery, is what the company said. And then Prasad comes out and says: No, they’re lying. That definitely could be a half-hour. No big deal. And I just think that there were senators frustrated with this, the White House not wanting to see another thing blow up over rare-disease drugs, because that has, there have been a lot of issues at FDA under his tenure, of just drugs not being able to get to market. Or having issues with vaccines that have been years in development not being able to get even reviewed, and then that being reversed. So it was just, that was kind of the last straw.
Rovner: And of course President Trump himself has been a big proponent of this whole Right to Try effort, that it should be easier for people with, particularly with terminal diseases to be able to try drugs that may or may not help. Joanne, you want to add something.
Kenen: Also wasn’t he still, Prasad, still living in California and running up really huge travel bills and—
Rovner: Yes.
Kenen: —not being at the FDA very much, at a time when everybody else has been forced to come back to work? So, but I do confess that I keep looking at my phone to check if he’s still out or is he already back again.
Rovner: Right.
Kenen: I’m really not totally convinced that this is the end of Prasad, but yeah.
Rovner: Yeah, I was not kidding when I said on-again off-again on-again off-again. All right. Well, moving over to the National Institutes of Health, which also has a director that’s doing more than one job in more than one place. I know there’s so much news that it’s hard to keep track of it all, but I do think it’s important to continue to follow things that look to be settled, like funding for the NIH, which Congress actually increased in the spending bill that passed at the end of January. To that end, a shout-out to our podcast panelist Sandhya Raman, formerly of CQ, now at Bloomberg, for grant funding that still pays for most of the nation’s basic biomedical research is still being held up. This is months after it was ordered resumed by courts and appropriated by Congress.
Shout-out as well to my Â鶹ŮÓÅ Health News colleagues Rachana Pradhan and Katheryn Houghton for their project on the people and research projects that have been disrupted by all the cuts at NIH, as well as new bureaucratic hurdles put in place. I feel like if there weren’t so much else going on, what’s happening at basically the economic and health engine of NIH would be getting much, much, much more attention, particularly because of the continuing brain drain with researchers moving to other countries and students choosing different careers rather than becoming researchers. I wonder if this sort of drip, drip, drip at NIH is going to turn into a very long-term hole that’s going to be very difficult to fill. A lot of these things have years- if not decades-long runways. These great scientific achievements start somewhere, and it looks like they’re just sort of pulling out the whole starting part.
Kenen: It’s already affecting the pipeline. In graduate schools, many schools fund their PhD candidates, and it’s NIH money, or partly NIH money. It’s different — I’m not an expert in every single school’s support systems for PhD candidates, but I do know that the pipeline has been shrunken in some fields at some schools, and that’s been reported on widely. And there’s been a lot of coverage about years and years of research. You can’t just restart a multiyear, complicated clinical trial or research project. Once you stop it, you’re losing everything to date, right? You can’t just sort of say, Oh, I’ll put it on hold for a couple of years and resume it. You can’t do that. So we’ve already reached some kind of a critical point. It’s just a matter of how much worse it gets, or whether the ship begins to stabilize in any way going forward. But there’s already damage.
Rovner: I say, are you guys as surprised as I am, though, that this isn’t — the NIH has been this sort of bipartisan jewel that everybody has supported over the decades that I’ve been covering it, and now it’s basically being dismantled in front of our eyes, and nobody’s saying very much about it.
Kenen: It’s also an engine of economic growth. You see different ROI [return on investment] numbers when you look at NIH, but I think the lowest number you hear is two and a half dollars of benefit for every dollar we invest. And I’ve seen reports up to $7. I don’t know what the magic number is, but this is an engine of economic growth in the United States. This is basic biomedical research that the private sector or the academic sector cannot do. It has to come from the government. And I don’t think any of us have really gotten our heads around — why harm the NIH when it is bipartisan, it is economically successful, and it has humanitarian value. It’s the basis. The drug companies develop the drug and bring it to the market. But that basic, basic, earlier what’s called bench science, that’s funded by the NIH.
Rovner: I know. It’s a mystery. Well, adding to RFK Jr.’s bad week are the growing divisions within his base, the Make America Healthy Again movement. While the White House, seeing that the public doesn’t really support MAHA’s anti-vaccine positions, is trying to get HHS to tone it down, there was a major MAHA meetup just blocks from the White House this week, with sessions urging a complete end to the childhood vaccine schedule and the removal of all vaccines from the market, quote, until they can be proven “safe and effective.” By the way, most of them have been already. Meanwhile, lots of MAHA followers are still angry that the White House is supporting the continuing production of glyphosate, the weed killer sold commercially as Roundup. Democrats, , are trying to exploit the divisions in the MAHA movement, which leads to the question: Will MAHA be a net plus or a net minus for this fall’s midterm elections? On the one hand, I think Trump appointed Kennedy because he was hoping that the MAHA movement would be a boost to turnout. On the other hand, MAHA seems pretty split right now.
Edney: Well, I think that’s the million-dollar question, is which way they’re going to swing if they swing at all. And it’s hard to say right now, because I think they are angry at certain aspects of things this administration is doing, the two things you mentioned, on Roundup and on vaccines, kind of telling RFK to kind of talk a little bit less about those. But will they be able to then vote for Democrats instead? I think, it’s only March, so it’s so difficult to say what will happen between now and then. I think there’s still things that the health secretary could do on food that he’s talked about, that could draw attention away from that anger, that might make many of them happy. I think there were some things he kind of started doing early in his term that hasn’t been talked about as much. And also, I think there’s still the prospect of Casey Means becoming surgeon general — or not — out there, and that’s kind of a big piece of this. If she is to get into the administration, and that is sort of up in the air right now, then that could kind of give them something else to focus on, because she is a large part of this playbook of the MAHA movement.
Rovner: That’s right. And we are waiting to see sort of if she can get the votes even to get out of committee, much less get to the floor, see whether we’re going to have, as some are saying, the first surgeon general who does not have an active license to practice medicine. Shefali, you wanted to add something.
Luthra: No, I just think we’ve talked about this before on the podcast, that the food stuff is much more popular than the vaccine stuff. The vaccine components of MAHA remain very unpopular. It’s difficult to really see or say sort of what the White House can do on food in a sustained, focused way, without going off-script, that is also popular. But I think to Anna’s point, it’s just so hard to say to what extent this ultimately matters in November, because there are just so many concerns right now. People can’t afford their health insurance, and gas prices are going up. And I just think we have to wait and see to what extent people are voting based on food policy.
Rovner: Yeah, well, we will see. All right, we’re going to take a quick break. We will be right back.
OK, turning to another Trump administration priority, fighting fraud. This week, the administration accused another Democratic-led state, New York, of not policing Medicaid fraud forcefully enough. This comes after the Centers for Medicare & Medicaid Services said it will withhold hundreds of millions of dollars from Minnesota, which our guest, Andy Schneider, will talk about at more length. Minnesota, by the way, last week sued the federal government over its Medicaid efforts. So that fight will continue for a while. But it’s not just blue states, and it’s not just Medicaid. In something I didn’t have on my bingo card, this administration is also going after fraud in the Medicare Advantage program, which has long been a Republican darling.
Last week, CMS banned the Medicare Advantage plan operated by Elevance Health, which has nearly 2 million Medicare patients currently enrolled, from adding any new enrollees starting March 31, for what the agency described as, quote, “substantial and persistent noncompliance with Medicare Advantage risk adjustment data.” And on Tuesday, the congressional Joint Economic Committee reported that overpayments to those Medicare Advantage plans raised premiums by an estimated $200 per Medicare enrollee annually — and that’s all Medicare enrollees, not just those in the private Medicare Advantage plans. Is this the end of the honeymoon for Medicare Advantage? Joanne, you were there with me when Republicans were pushing this.
Kenen: I’ve been surprised, as you have, Julie, because basically Medicare Advantage has been the darling, and it is popular with people. It’s grown and grown and grown, not because the government forced people in. It has good marketing and some benefits for the younger, healthier post-65 population, gyms and things like that. But — and vision and dental, which are a big deal. But we’ve also seen a backlash, in some ways, because there’s the prior authorization issues in Medicare Advantage have gotten a lot of attention the last couple of years. But not just am I surprised by sort of the swing that we’re hearing about generally. I’m surprised by Dr. Oz, because when he ran for Senate a couple years ago in Pennsylvania, and much of his public persona has been really, really, really gung-ho, pro Medicare Advantage.
And yet, some of you were at or, like me, watched the live stream of — he did a very interesting, thoughtful, and, I’ve mentioned this at least one time before, hourlong conversation with a lot of Q&A at the Aspen Institute here in D.C. a couple of months ago. And one of the questions was someone said: Dr. Oz, you’ve just turned 65. Are you doing Medicare Advantage, or are you doing traditional Medicare? And the expected answer for me was, well, I knew that he’s on government insurance now. So he, you have to, at 65 you have to go into Medicare Advanta— Medicare A, whether you — that’s automatic. That’s the hospital part. But you have the choice. But if you’re still working and getting insurance or government — he’s on a government plan. He doesn’t have to do that. But he actually, and he pointed that out, but the next sentence really surprised me, because he said: I don’t know. My wife and I are still talking about that. And I thought that was A) a very honest answer. He didn’t have to even say. But it was also, it just was interesting to me that after all that Rah-rah Medicare Advantage we were hearing about, his own personal choice was, Not sure if that one’s right for me. ³§´Ç&²Ô²ú²õ±è;—&²Ô²ú²õ±è;
Rovner: I was going to say, I feel like the Republicans are sort of twisting right now between Medicare Advantage, which they’ve always pushed — they want to privatize Medicare because they don’t like government health insurance — and then there’s the current populist push against big insurance companies, because, of course, all those Medicare Advantage plans belong to those big insurance companies that Republicans are suddenly saying are too big and getting too much money. So they’re sort of caught between trying to have it both ways. I’ll be interested to see how they come down. One of the things that did strike me, though, even before Dr. Oz sort of started his little crusade against Medicare Advantage, was, I think it was at Kennedy’s confirmation hearing that Sen. Bill Cassidy was suddenly questioning Medicare Advantage. That was, I think, the first Republican I saw to like, Oh. That made me raise my eyebrows. And I think since then, I’ve kind of seen why.
Kenen: The populist talk against insurance companies, not giving money to insurance companies, is part of the Republican — and, specifically, President Trump’s — desire to not extend the ACA, the Affordable Care Act, enhanced subsidies. That was the basic: Well, we’re not going to do this, because we’re just throwing money at these insurance companies. And we don’t want to do that. We want to empower the patients. That was the, I’m not, and the missing piece of that argument is: Yes, the ACA subsidies go to insurance companies. However, all of us are benefiting in some way or other from government policies that benefit insurance companies. The tax breaks our employers get. The tax breaks we get for our insurance. And then the biggie, of course, is Medicare Advantage.
We are paying Medicare Advantage more than we are paying traditional Medicare. So Medicare Advantage is private insurance companies, and the government has been just sending them lots and lots of money for years. So I’m not sure it’s — this Medicare Advantage thing is just bubbling up, and we’re not really sure how this plays out. But I think that the rhetoric against insurance companies is the rhetoric against the ACA.
Rovner: Oh, it is.
Kenen: Rather that hasn’t yet been connected to the Medicare Advantage. I think they’re, yes, we all know they’re connected. But I think the political debate, it’s not Medicare Advantage is bad because insurance companies are bad. It’s the ACA is bad because it enriches insurance companies. There’s a different ideological parade going down the road.
Rovner: I was going to say, it’s important to remember at the beginning of Medicare Advantage, which was a Republican proposal back in 2003, they purposely overpaid it. They gave it more money because they know that when they give them more money, the insurance companies are required to return some of that money to beneficiaries in the form of these extra benefits. That’s why there are gym memberships and dental and vision and hearing coverage in these Medicare Advantage plans. It does make them popular, so people sign up. And that was sort of Republicans’ intent at the beginning. It was to sort of not so much push people into it but entice people into it.
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Rovner: And then maybe cut it back later.
Kenen: No, but it’s exceeded expectations.
Rovner: Absolutely.
Kenen: The number of people going into Medicare Advantage has been really high, higher than people expected. And it’s also hard to get out, depending on what state you live in. It’s not impossible, but it’s costly and difficult, except for a few, I think it’s seven or eight states make it pretty easy. But also remember that the earlier version of what we now call Medicare Advantage was — which was the ’90s, right Julie? — I think the Medicare Part C, and that failed. ³§´Ç&²Ô²ú²õ±è;—&²Ô²ú²õ±è;
Rovner: Well after, that failed because they cut it when they were —
Kenen: Right. Right.
Rovner: They cut all the funding when they were balancing the budget —
Kenen: Right.
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Kenen: But that gave them the excu— right.
Rovner: They made it fail.
Kenen: That gave them an excuse to give them more money later that, when they revived it, renamed it, and launched it in 2003 legislation, that initial push to give them a ton of money, because they could say, Well, we didn’t give them enough money, and that’s why they fa—. There are all sorts of political things going on that weren’t strictly money. But yeah, it was part of the narrative of Why we have to give them more money, is They need it.
Rovner: Yeah. Anyway, we’ll also watch that space. Well, finally, this week, there’s news on the reproductive health front, because there’s always news on the reproductive health front. Shefali, Wyoming has become the latest state to enact a so-called heartbeat ban, barring abortions when cardiac activity can be detected. That’s often around six weeks, which is before many people are even aware of being pregnant. I thought the Wyoming Supreme Court said just this past January that its constitution prevents abortion bans. So what’s up here?
Luthra: They did, in fact, say that, and so we are seeing this law taken to court. It was actually added in a court filing to a preexisting case challenging other abortion restrictions in the state. I’m sure that’s going to play out for quite some time. But what’s interesting about the Wyoming Constitution — right? — is that it protects the right to make health care decisions, in an effort to sort of fight against the ACA. That was this conservative approach that now has come to really benefit abortion rights supporters as well. But what I think this underscores is that even as we are seeing fairly little abortion policy in Washington, at least in a meaningful way, a lot is still happening on the state level. That really is where the bulk of action is, whether you see that in Wyoming, in Missouri, where they’re trying to undo the abortion rights protections there, and just—
Rovner: The ones that passed by voters.
Luthra: Exactly. And so what we’re really thinking about is anti-abortion activists are not really that confident in the president’s desire, interest, ability, what have you, to get their agenda items done. And for now, they are really focusing on the states, and that is where their interest, I think, will only remain, at least until the primary for the next presidential race begins in earnest.
Rovner: Well, Shefali, I also want to ask you about this week on just how many things ripple out economically from abortion restrictions. Now it’s having an impact on rent prices? Please explain.
Luthra: I thought this was so interesting. It was this NBER [National Bureau of Economic Research] paper that came out this week, and they looked at comparably trending rental markets in states with abortion bans and those without them. And what they saw was that after the Dobbs decision, rental prices declined relative to places without bans, compared to those in those that had them. And this is really interesting. It just sort of continues. Rental prices went down, and also vacancies went up. And what the researchers say is this is a very, very dramatic and clear relationship, and it illustrates that people, when they have a choice, are considering abortion rights in terms of where they want to live. And anecdotally, we know that, because we’ve seen residents make choices about where they will practice. We’ve seen doctors decide where they will live. We have seen people move. Companies offer relocation benefits if people want them. And this is more data that illustrates that actually that affects the economy of communities, and it really underscores that where we live just simply will look different based on things like abortion rights and abortion policy and other of these things that are treated as social but really do affect people’s economic behaviors.
Rovner: And as we pointed out before, it’s not just about quote-unquote “abortion,” because when doctors choose not to live in a certain place, it’s other types of health care. It’s all health care. And we know that doctors tend to marry or partner with other doctors. So sometimes if an OB GYN doesn’t want to move to a certain place, then that OB-GYN’s partner, who may be some completely other type of doctor, isn’t going to move there either. So we are starting to see some of these geographical shifts going on.
Luthra: And one point actually that the researcher made that I thought was so interesting was that abortion policy, it can be emblematic, in and of itself, a reason people choose not to live somewhere, but people may also be making these decisions because of what it represents. Do I look at an abortion policy and say, Oh, this reflects social values or gender beliefs? Or does it also suggest maybe more anti-LGBTQ+ laws? And all of that can create a picture that is broader than simply abortion or not, and determine where and how people want to live their lives.
Rovner: It’s a really interesting story. We will link to it. All right, that is this week’s news. Now I’ll play my interview with Andy Schneider of Georgetown University, and then we will be back to do our extra credits.
Rovner: I am pleased to welcome to the podcast Andy Schneider, a research professor of the practice at the Georgetown University McCourt School of Public Policy. And he spent many years on Capitol Hill helping write and shape Medicaid law as a top aide to California Democratic congressman Henry Waxman — and many hours explaining it to me. I have asked him here to help untangle the Medicaid fraud fight now taking place between the federal government and, at least so far, mostly Democratic-led states. Andy, thanks for being here.
Andy Schneider: Thanks for having me, Julie.
Rovner: So, it’s not like fraud in Medicaid — and other health programs, for that matter — is anything new. Who are the major perpetrators of health care fraud? It’s not usually the patients, is it?
Schneider: No, it’s usually some bad-actor providers or bad-actor businesspeople.
Rovner: So how are fraud-fighting efforts at both the federal and state level, since Medicaid funding is shared, supposed to work? How does the federal government and the state government sort of try and make fraud as minimal as possible? Since presumably they’re never going to get rid of it.
Schneider: Unfortunately, I don’t think you’re ever going to get rid of it in Medicaid or Medicare or private insurance or in other walks of life. There are bad actors out there. They’re going to try to take advantage. So you need your defenses up. So the short of this is, Medicaid is administered on a day-to-day basis by the states. The federal government pays for a majority of it and oversees how the states run their programs. In that context, the state Medicaid agency and the state fraud control unit have a primary role in identifying where there might be fraud, investigating, and then, in appropriate cases, prosecuting. The federal government also has a role, however. Depending on the scope of the fraud, it could involve the FBI. It could involve the Office of Inspector General at the Department of Health and Human Services. So there’s both federal and state presence, but the primary responsibilities were the states’.
Rovner: We know that Minnesota has been experiencing a Medicaid fraud problem, because both the state and the federal government have been working on it for more than a year now. What is the Trump administration doing in Minnesota? And why is this different from what the federal government has traditionally done when it’s trying to ensure that states are appropriately trying to minimize fraud?
Schneider: Well, usually the vice president of the United States does not get up at a White House press conference and announce he and the Centers for Medicare & Medicaid Services are withholding $260 million in federal funds, called a deferral. That is highly, highly unusual. And normally the head of the Centers for Medicare & Medicaid Services does not go and make videos in the state before something like this is announced. So I would say that this is way out of the ordinary, and I think it has to do with some animus in the administration towards Gov. [Tim] Walz and his administration.
Rovner: Right. Gov. Walz, for those who don’t remember, was the vice presidential candidate in 2024 running against President Trump, who did win, in fact. But there have been two different efforts to withhold Medicaid money for Minnesota, right?
Schneider: Yeah. Now you’re into the Medicaid weeds, but since you asked the question, I’ll take you there. So in January, the administra— the Center for Medicare & Medicaid Services — we’ll call them CMS here — they announced they were going to withhold about $2 billion a year going forward, not looking back but going forward, in matching funds that the federal government would otherwise pay to the state of Minnesota for the services that it was providing to its over 1 million beneficiaries. In February at this White House press conference, what the vice president announced was withholding temporarily — we’ll see how temporary it is — but withholding temporarily $260 million in federal Medicaid matching funds that applied to state spending that’s already occurred, happened in the past, happened in the quarter ending Sept. 30, 2025. So both the past expenditures and future expenditures are targets for these CMS actions.
Rovner: So what happens if the federal government actually doesn’t pay the state this money? I assume more than people who are committing fraud would be impacted.
Schneider: Well, let’s be clear. The amounts of money here, there’s no relationship between those and however much fraud is going on in Minnesota. And there has been fraud against Medicaid in Minnesota. Everybody’s clear about that. The state is clear about it. The feds are clear about it. But $2 billion going forward in a year, $1 billion going, looking backwards, $260 million times four — there’s no relationship between those amounts, right? Should they come to pass —and all of this is still in process — should those amounts come to pass, you’re looking at, depending on who’s doing the estimates, between 7 and 18% of the amount of money the federal government pays, helps the state with, each year in Medicaid. That’s just an enormous hole for a state to fill, and it doesn’t have many good options. It can cut eligibility. It can cut services. It can cut reimbursement rates. Filling in that hole with state revenues, that’s going to be a real stretch.
Rovner: So it’s not just Minnesota. Now the administration says it is seeing concerning things going on in New York and has launched a probe there. Is there any indication that this administration is going after states that are not run by Democrats?
Schneider: So the only letters that we’ve seen from the administration have been to California, New York, and Maine. There may be other letters out there. We only access the public record. So so far, based on what we know, it’s just been Democratically run states.
Rovner: As long as I’ve been covering this, which is now a long time, fraud-fighting has been pretty bipartisan. It’s been something that Congress has worked on, Democrats and Republicans in Congress, Democrats and Republicans in the states. What’s the danger of politicizing fraud-fighting, which is what certainly seems to be going on right now?
Schneider: Yeah, that’s a terrific point. So it always has been bipartisan, because money is green. It’s not red. It’s not blue. It’s green. And trying to keep bad actors from ripping it off from Medicaid or Medicare has always been a bipartisan undertaking. The reason that’s important, particularly in a program like Medicaid, where the federal government and the state have to talk to one another when they are flagging potential fraud, when they’re investigating it, when they’re prosecuting it, you don’t want the agencies tripping all over one another. You want them sharing information as necessary, etc. When that gets politicized, it’s very bad for the results and for the effective operation of the program.
Rovner: Well we will keep watching this space, and we’ll have you back to explain it more. Andy Schneider, thank you very much.
Schneider: Julie Rovner, thank you very much.
Rovner: OK, we’re back. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think you should read, too. Don’t worry if you miss it. We will post the links in our show notes on your phone or other mobile device. Anna, why don’t you start us off this week?
Edney: Sure. Mine is in The Wall Street Journal. It’s [“”]. This is a look at the booming business of providing therapy to children with autism. And that’s particularly been big in the Medicaid program. And I don’t want to give away too much, because there are just so many jaw-dropping details in this. So I guess the reporters were able to kind of go through the data and billing records in a way that showed some of these companies and what they were doing and how they were becoming millionaires, people who had never done anything in autism before. So if you enjoy a sort of jaw-dropping read, I think you should take a look at it.
Rovner: Yeah, jaw-dropping is definitely the right description. Joanne.
Kenen: So I sort of rummaged around the internet to the less widely read sources, and I came across this great story from the Idaho Capital Sun by Laura Guido. It has a long headline. Reminder that 988 is the mental health crisis line and suicide help. The headline is: “” The story is that a 15-year-old boy named Jace Woods called two years ago — so this still hasn’t been fixed after two years — and they cut him off. They sort of gently cut him off. But they can’t talk to these kids who have, who are in crisis, without parental consent. They do a quick assessment. If they think someone’s life is immediately in danger right then and there, they can stay on. But a kid who’s what they call suicidal ideation, seriously depressed and at risk, and knows he’s at risk or she’s at risk, and made this phone call, they don’t talk to them unless they think it’s imminent. So it also affects, these parental, it affects sexual health and STDs and abortion and whole lot of other things.
Rovner: That’s what it was for.
Kenen: That was the initial reason, but it got bigger. So a kid who calls in a crisis can get no help at all. And even in those emergency situations where they can stay on the line and try to get emergency help if they do think a kid’s in imminent danger, they’re not allowed to make a follow-up call to make sure they’re OK. So this kid has been trying for two years. There’s a state lawmaker. They’re refining a law. They say it’s, they’re refining a bill. They say it’s going to go through. But really this, talk about unintended consequences. We have a national mental health crisis, particularly acute for teens. This is not solving any problems.
Rovner: It is not. Shefali.
Luthra: My story is in The New York Times. It is by Apoorva Mandavilli. The headline is “.” And it’s just a good story about what is happening with the Ryan White AIDS Drug Assistance Programs, which people use to get their HIV medications paid for or for free. They get insurance support. And these are really important. Funding has been pretty flat for quite some time because they’re funded by Congress. And what the story gets into is that with growing financial pressure on these programs, there is more-expensive drugs, there are more-expensive insurance premiums, more people might be losing Medicaid. States are having to make very difficult choices, and they are cutting benefits. They are changing who is eligible, because it’s getting more expensive and there is more need and there is no support coming. And I wasn’t really on top of this and did not know what was going on, and I just thought it was interesting and a very useful look at some of the consequences of the policy choices that are making all of these health programs more expensive and health care, in general, harder to afford.
Rovner: My extra credit this week is from The Marshall Project. It’s called “.” It’s by Shannon Heffernan and Jesse Bogan and Anna Flagg. It answers the question that I’ve been wondering about since the whole immigration crackdown began, which is: What happens to the people who are snatched off the streets or out of their cars or homes, flown to a distant state, and then someone says: Oops, sorry. You can go. How do you get home from Texas or Louisiana to Minnesota or Massachusetts? Authorities don’t give you plane or even bus tickets to get back to where you were picked up, even though that’s where most of those being released are required to go to report back to immigration authorities. It turns out there’s a small network of charities that is helping. But as the story details pretty vividly, the harm to these families doesn’t end when their detention does./
OK. That’s this week’s show. As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer. Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, , or on Bluesky, . Where are you guys hanging these days? Shefali?
Luthra: I am at Bluesky, .
Rovner: Anna.
Edney: and , @annaedney.
Rovner: Joanne.
Kenen: A little bit of and more on , @joannekenen.
Rovner: We will be back in your feed next week. Until then, be healthy.
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And subscribe to “What the Health? From Â鶹ŮÓÅ Health News” on , , , , , or wherever you listen to podcasts.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/podcast/what-the-health-437-rfk-jr-kennedy-casey-means-prasad-march-12-2026/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2168125&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>We Have Invested Too Much To Let Research Programs Die Quietly
I have dedicated my life to research, but now that work, along with the trust, data, and progress behind it, is at risk (“NIH Grant Disruptions Slow Down Breast Cancer Research,” Feb. 3).
As a rheumatologist and researcher, I have spent decades studying lupus — a chronic autoimmune disease that can affect nearly every organ system, producing symptoms that are often unpredictable and difficult to manage. Its impact on a patient’s quality of life is profound: Nearly 90% of people with lupus report being unable to maintain full-time work, while many also face interruptions in education or career progression.
But funding uncertainty from the National Institutes of Health, the Centers for Disease Control and Prevention, and other federal programs means that the thousands of patients involved in my research, along with millions of patients nationwide, are at risk. While I appreciate the increase in lupus research funding included in the recently passed congressional funding package, funding disruptions persist nationwide, and recovery takes time.
Increased funding is not like a light switch that we can just turn back on. It will take a lot of time to recruit back those we lost. That doesn’t include the young investigators who would have entered the field and are now lost. It takes time to build back the broken trust and infrastructure needed to keep participants engaged and ensure reliable data.
Medical research connects the bedside to the database to the policymaker’s desk. Without it, we are blind to the very problems we most urgently need to solve. The window to save these programs is closing. We must act now before it’s too late.
— S. Sam Lim, Atlanta
Knocking Down Barriers to Long-Term Hospital Care
For many Americans, being released from their initial hospital stay is just the beginning of their care journey. Depending on the complexity of one’s condition and the clinical need for more specialized post-acute services such as ventilation, long-term care hospitals, or LTCHs, offer highly personalized care to individuals recovering from a catastrophic illness or injury (Broken Rehab: “They Need a Ventilator To Stay Alive. Getting One Can Be a Nightmare,” Dec. 2).
LTCHs play a critical role in the nation’s health care system by providing complex, resource-intensive care to patients leaving acute-care hospitals but who still need sustained support and treatment. Not only do LTCHs help patients who are dependent on ventilation, have complex wounds, or have multiple organ failure, they also serve as a relief valve in our nation’s hospital system by helping free up beds and resources at general hospitals.
However, the ability to access this vital form of care is becoming increasingly difficult — underscoring the need for lawmakers in Washington to act. Since 2016, over 100 LTCHs have closed due to chronic underpayments amid higher costs. This has been exacerbated by Congress’ decision to implement changes to how it reimburses LTCHs for its beneficiaries. As a result, patients have fewer options, and the facilities that remain open are often far away from home for patients and families, particularly in rural areas. Furthermore, insurance company barriers — such as prior authorization requirements put in place by Medicare Advantage plans — are creating harmful delays and denials of necessary and time-sensitive patient care. Consequently, many patients are denied access to an LTCH setting — or transferred to other post-acute care settings like rehabilitation or skilled nursing facilities that aren’t equipped to care for patients with highly complex needs like ventilation.
America’s sickest patients deserve the right level of care at the right time. As this need becomes more urgent by the day, policymakers must work to address these challenges and strengthen access to LTCHs, which help patients get transferred out of the hospital quicker, reduce hospital overcrowding, and ultimately save lives.
— Jim Prister, Chicago; president and CEO of RML Specialty Hospital; chair of the American Hospital Association’s Post-Acute Care Steering Committee
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .
This <a target="_blank" href="/letter-to-the-editor/reader-letters-congress-action-research-long-term-care-hospitals-march-2026/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2161001&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>The retiree, 70, was diagnosed with glaucoma in her right eye in 2019. She had a laser procedure to treat it in 2022, and she uses medicated drops in both eyes to prevent more damage. She is supposed to be checked regularly, she said.
During the May appointment, Tuszynski’s optometrist examined her eyes and reassured her that the glaucoma had not worsened.
Tuszynski, who lives in central Wisconsin, had looked up beforehand whether the clinic in nearby Madison participated in her insurance plan. The insurer’s website listed the optometrist’s name with a green check mark and the words “in-network.” She assumed that meant her policy would cover the appointment.
Then the bill came.
The Medical Procedure
An optometrist tested Tuszynski’s vision and took pictures of her optic nerves.
The Final Bill
$340, which included $120 for vision testing and $100 for optic nerve imaging.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .
This <a target="_blank" href="/health-care-costs/medicare-advantage-eye-care-wisconsin-bill-of-the-month-january-2026/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2149694&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>
The actions of federal Immigration and Customs Enforcement agents are having ramifications far beyond immigration. Medical groups say that ICE agents in health facilities in Minneapolis and other cities are imperiling patient care, while in Washington, the backlash from a second fatal shooting by agents in Minnesota has stalled action on an eleventh-hour suite of spending bills.
Meanwhile, anti-abortion groups remain unhappy with the Trump administration over what they see as its reluctance to scale back the availability of the abortion pill mifepristone.
This week’s panelists are Julie Rovner of Â鶹ŮÓÅ Health News, Maya Goldman of Axios, Alice Miranda Ollstein of Politico, and Rachel Roubein of The Washington Post.
Panelists
Among the takeaways from this week’s episode:
- Concerns intensified this week over President Donald Trump’s immigration sweep after federal agents killed a second citizen in the midst of the crackdown in Minneapolis. Democrats in Congress are blocking approval of government spending as they call for renegotiating Department of Homeland Security funding, potentially forcing a partial government shutdown this weekend. In Minnesota and elsewhere, there are reports of patients postponing medical care and doctors pushing back on the presence of federal agents in hospitals.
- After the Department of Health and Human Services cut off some federal funding to Minnesota over allegations of Medicaid fraud, other Democratic-led states in particular are fearing HHS could do the same to them. Typically the federal government conducts investigations and imposes sanctions in response to concerns of fraud; it’s unusual that HHS has opted to halt some funding instead.
- Abortion opponents last week held their annual March for Life in Washington. The Trump administration marked the occasion by reinstating and expanding policies imposed during the president’s first term, including a ban on fetal tissue research and what’s known as the Mexico City Policy. Still, the administration has not made notable progress on a key goal of the anti-abortion movement: barring access to medication abortion.
- Meanwhile, senators are still trying to sort out a bipartisan compromise to restart the enhanced Affordable Care Act premium subsidies that expired last year. And insurance company executives appeared before House lawmakers last week to answer questions about affordability as the Trump administration announced a plan to keep reimbursement rates nearly flat next year for private Medicare Advantage plans.
And Â鶹ŮÓÅ Health News’ annual Health Policy Valentine contest is open. You can enter the contest here.
Plus, for “extra credit” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: Science’s “,” by Monica Hersher and Jeffrey Mervis.
Maya Goldman: NBC News’ “,” by Berkeley Lovelace Jr.
Alice Miranda Ollstein: The New York Times’ “,” by Kenneth P. Vogel and Christina Jewett.
Rachel Roubein: Stat’s “,” by O. Rose Broderick.
Also mentioned in this week’s episode:
- Axios’ “,” by Maya Goldman.
- Annals of Internal Medicine’s “,” by Jeremy W. Jacobs, Garrett S. Booth, Noel T. Brewer, and Janet Freilich.
- Politico’s “,” by Alice Miranda Ollstein.
- The Washington Post’s “,” by Lena H. Sun and Rachel Roubein.
- The Georgetown University Center for Children and Families’ “,” by Andy Schneider.
- Â鶹ŮÓÅ’s “,” by Shannon Schumacher, Audrey Kearney, Mardet Mulugeta, Isabelle Valdes, Ashley Kirzinger, and Liz Hamel.
[Clarification: This article was revised at 12:30 p.m. ET on Jan. 30, 2026, to clarify that the agents involved in the Trump administration’s immigration crackdown represent not only the U.S. Immigration and Customs Enforcement agency but also the broader Department of Homeland Security.]
[Editor’s note: This transcript was generated using transcription software. It has been edited for style and clarity.]
Julie Rovner: Hello from Â鶹ŮÓÅ Health News and WAMU public radio in Washington, D.C. Welcome to What the Health? I’m Julie Rovner, chief Washington correspondent for Â鶹ŮÓÅ Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, Jan. 29, at 10 a.m. As always, news happens fast and things might have changed by the time you hear this. So, here we go.
Today we are joined via videoconference by Alice Miranda Ollstein of Politico.
Alice Miranda Ollstein: Hello.
Rovner: Maya Goldman of Axios News.
Maya Goldman: Hi.
Rovner: And Rachel Roubein of The Washington Post.
Rachel Roubein: Hi, everyone.
Rovner: No interview this iced-in week here in Washington, but still lots of news. So last week at this time, Congress was busy patting itself on the back for being poised to pass all 12 annual appropriation bills before their Jan. 30 deadline, including the two biggest ones, those funding the Departments of Defense and Health and Human Services. Still, as I believe I said at the time, it’s not done until it’s done, and, well, it’s not done. What happened, of course, is that after the House passed the remaining six spending bills and left for a week’s recess, on Saturday, federal [Border Patrol] officers shot and killed a VA [Department of Veterans Affairs] ICU nurse, Alex Pretti, on the streets of Minneapolis, where he was participating in an ICE [Immigration and Customs Enforcement] protest. That second killing of a civilian in three weeks turned Senate Democrats, who were supposed to approve the spending package this week, unanimously against the spending bill for the Department of Homeland Security, which includes ICE and which is included within the appropriations package passed by the House last week. But it’s not as easy as splitting off the Homeland Security bill and passing the other five. If the Senate changes anything about the package, it has to go back to the House, which, as I mentioned, isn’t even in town this week. So where are we? And how likely is it that we’re going to look at a partial government shutdown come Saturday?
Ollstein: So it’s really a mess right now. You have some in both parties who are calling for passing the rest of the bills and pulling out the Homeland Security funding to keep negotiating. Some people are saying they should do a very short-term CR [continuing resolution] — a week, a couple weeks — in order to give Congress more time to negotiate these reforms and restrictions that Democrats are demanding. But then you have House Republicans who are saying, Oh, if we’re opening this all back up again, we have some demands, too, and we want more of this and more of that and XYZ. And so they’re saying, We’re gonna defund all sanctuary cities. So, like you said, once you open this back up, it opens up a whole can of worms. That said, the Democrats’ base is really saying don’t give one penny more to this agency that they see as completely running amok and violating life and civil liberties. And so we’re really at kind of an impasse right now.
Rovner: This is a classic never-count-your-chickens in Congress. Maya, you want to add something.
Goldman: Yeah, I was going to say, it seems like the health care package is collateral damage here, right? There’s a lot of agreement, bipartisan agreement, that these changes that they’re trying to make, PBM [pharmacy benefit manager] changes, things like that, should be passed. But then, like you said, Julie, it’s never over till it’s over, and more time between getting a bill negotiated and actually passing it just gives interest groups more time to get things changed. So that will be interesting to see.
Rovner: And just a reminder for those who aren’t following this as closely as we are, there is this health package that’s riding along in this spending-bill package that includes the PBM reform and extensions for things like home health care and telehealth and other things that are not technically spending-bill issues but that need to be renewed periodically by Congress. So that’s also sitting out there waiting to see what the Senate decides to do and then what the House decides to do, depending on what the Senate decides to do.
Roubein: And the last government shutdown, in the fall, was based on health care. But as you mentioned, the fight was over Affordable Care Act subsidies, which is not part of this package that Julie mentioned.
Rovner: That’s right. So that will continue. But I want to talk about ICE. We have tiptoed into the immigration debate as it impacts health care in recent months, but now it’s really front and center, and I’m talking about more than just the fight over ICE tactics in Minnesota and blocking the spending bill for the entire Department of Health and Human Services. Maya, about how ICE presence in hospitals and other health care facilities is having an impact on patient care. Tell us what you found.
Goldman: Yeah, a lot of physicians and nurses in Minneapolis, Twin Cities, and also across the country are saying that this is approaching, or has already become, a public health crisis. And the problem is twofold. It’s, Part 1, patients aren’t coming to get the care that they need, because they’re worried about leaving their homes. And one doctor during a press conference said she even has patients who don’t want to take telehealth appointments, because they’re afraid of getting on the phone or getting on the computer, because they’re worried they’re being surveilled. So that’s a huge problem. And then some doctors are also saying that ICE presence in and around hospitals is making it harder for them to do their jobs of providing care, because there are reports of agents being aggressive and sort of being in places where they are not supposed to be, or are physically impeding care. So two sides of the coin.
Rovner: Yeah, a reminder that ICE was largely forbidden from operating in, quote, “sensitive” areas like schools and churches and health facilities, in both Republican and Democratic administrations, until [President Donald Trump] changed it last January. We’ve heard a lot since then about ICE being in all of these sensitive locations, right?
Goldman: Yeah, yeah. And I think it’s important to note the Department of Homeland Security, when I reached out to them, said that they are not conducting enforcement operations in hospitals, even though they are now allowed to. If they take a patient who’s in custody to the hospital, they are in the hospital. They can get a warrant to come into the hospital. They can be in public spaces like parking lots and waiting rooms, waiting for people.
Rovner: And as we’re hearing, that’s exactly what they’ve been doing.
Goldman: Exactly.
Rovner: Even though they’re not, quote-unquote, “conducting enforcement operations” there. Doesn’t mean they’re not there. So even the American Medical Association, not exactly a left-wing group, issued a statement expressing concern about ICE activity in and around hospital emergency rooms, which it called a, quote, “tactic fueling fear among patients and hospital staff alike.” Are we starting to turn a corner here? I feel like this is, maybe it was a combination of what happened last week, coincided with the big snowstorm in half the country and people were stuck inside watching TV. I do feel like there’s way more awareness than there was even two or three weeks ago of this stuff.
Ollstein: I think it remains to be seen whether there is a meaningful policy and practice change or just a sort of symbolic or rhetorical change. There’s a different tone being struck. There’s sort of backpedaling on the immediate reaction from government officials we heard, which was to blame the people who were killed for their own killings. There are calls for investigations coming from both sides of the aisle. There are calls for some top officials’ resignations. But again, we’re hearing from people on the ground that things have not actually shifted in the enforcement behavior of these agents. And so I think it really remains to be seen what happens in Congress in terms of passing policies. There’s discussion of putting limitations in the spending bill on what ICE can do. But again, there is a lot of concern that I’ve heard from the advocacy community that they’re going to set up some government official — whether it’s [Homeland Security Secretary] Kristi Noem or [Trump deputy chief of staff] Stephen Miller or, already we’ve seen [Border Patrol official Gregory] Bovino — to be a fall guy and then nothing will actually change substantially beyond that. And so there’s continued anxiety around that.
Rovner: Yeah, and just a reminder that even if the spending bill doesn’t, for the Department of Homeland Security, didn’t pass and they didn’t even do a continuing resolution, ICE has I believe it’s $75 billion from the budget bill that passed last year. So they have a big chunk of money to keep operating regardless. Talk about collateral damage — it would be all of these other agencies that would have to sort of stop operating if there is some kind of a shutdown.
Well, meanwhile, it’s not just ICE that’s going after the state of Minnesota. The Centers for Medicare & Medicaid Services earlier this month cut off a chunk of the state’s Medicaid funding going forward. They’re charging that the state is, quote, “operating its program in substantial noncompliance” with rules to detect waste, fraud, and abuse. This is not how this is supposed to work. CMS can sanction states for their anti-fraud efforts being lacking, but there’s supposed to be a lot of due process first, with lots of hearings and appeals and fact-finding and all kinds of mumbo jumbo that we do go through before people actually get sanctioned. That’s apparently not what’s happening here. Although the ICE headlines are overshadowing the other punitive measures the federal government is taking toward Minnesota, I’m kind of surprised this aspect of the story isn’t getting more attention. Might it when other governors realize that this could happen to them, too, even if they didn’t happen to be on the ballot against Trump in the last election, like Minnesota Gov. [Tim] Walz was?
Goldman: Yeah, I was talking to somebody in the Medicaid space from a different blue state who was saying this feels like a turning point, something that they are scared of happening in their state as well. And, yeah, I think there are a lot of things that we need to see how they’ll play out, but this is definitely raising eyebrows.
Rovner: Yeah, and I will post in the show notes by Andy Schneider — who’s at Georgetown University and who wrote, when he worked on the Hill, wrote a lot of the Medicaid statute — explaining how this is all supposed to work and quite how different this is. But I would expect to be hearing more about this in the coming days and weeks, particularly if the administration doesn’t back off, because it’s a lot of money and, as we know, Medicaid is a huge, huge piece of every single state’s budget.
Well, meanwhile, on the abortion front, last week was the annual March for Life, marking the anniversary of the now overturned Supreme Court decision Roe v. Wade, and it’s fair to say that the anti-abortion movement is not happy with the Trump administration’s actions so far on the issue. Let’s start with what the administration did do to prove its devotion to the anti-abortion cause, To mark the movement’s big day in D.C., the Department of Health and Human Services reinstated its first-Trump-term ban on the use of fetal tissue in biomedical research, which President [Joe] Biden had reversed, and it expanded pretty dramatically the so-called Mexico City Policy that bans U.S. funding for international groups that, quote, “perform” or “promote” abortion. Now things like DEI [diversity, equality, and inclusion] and gender-affirming care are included, too. Alice and Rachel, you guys cover this. What should we know about these two new policies? It doesn’t seem like much, because they had both been in effect before, but it’s pretty big.
Ollstein: So the fetal tissue ban is also, research, is also an expansion of the first-term version, just like the Mexico City Policy. It goes further than before. And so the new version bans not only in-house government research but also government funding of research at outside institutions that use fetal tissue that was donated from abortions, and that has been used in all kinds of really important medical research, development of vaccines, etc. And so there is a lot of concern about that. They also imposed new restrictions on accepting new stem cell lines. There are lots of existing stem cell lines that they just keep propagating over and over from a long time ago, but they’re pausing accepting new ones while, they say, they’re exploring alternatives that they find more ethical. All of this has really rattled the research community.
And as for the Mexico City Policy, the expansion there is far beyond the issue of abortion. It’s banning funding going to groups that promote what they consider DEI and what they consider gender ideology. And so this is groups that serve the trans community in other countries and have programs for specific marginalized groups. So again, a lot of concern in the public health world because in order to tackle big public health problems, you often need to direct resources to the communities most at risk, and often that is the trans community, that is racial minorities. And so there’s a fear of this really impeding the delivery of services in a way that will impact the broader population.
Rovner: All right, so now to what the administration didn’t do that makes the anti-abortion movement so unhappy — anything further to restrict the abortion pill mifepristone. In fact, as expected, the Justice Department filed its brief in a closely watched lawsuit out of Louisiana this week, urging the court to pause the suit while the FDA [Food and Drug Administration] finishes its study of mifepristone, a study that abortion opponents say is the FDA purposely using to drag its feet on any action. So what the heck is going on here? Rachel, you start.
Roubein: Yeah, basically the Department of Justice in this lawsuit in Louisiana, and basically their justification was that: The Food and Drug Administration is reviewing mifepristone. We need time to do that. So that was basically what their ask was, was, like: Put this on pause. We will do this review that, as you said, anti-abortion advocates have been upset and said that it has been moving too slowly.
Ollstein: So I really saw the legal brief was kind of a Rorschach test that people could see different things and signs in it, because you had the pro-abortion-rights community looking at them saying: Look, they’re saying that the FDA didn’t properly review this in the past, and that’s why they’re doing this rigorous review now. That’s a sign that they’re going to impose restrictions. Also, the anti-abortion side looked at it and they were upset, one, that the Justice Department is arguing that the FDA allowing telemedicine doesn’t harm the states, and the states believe that it does, and so they’re saying: You can’t prove harm. You don’t have standing to bring this case. I think really the common theme in this filing and in some other ones last year related to these state abortion lawsuits is that the Trump administration is defending federal power and federal decision-making, and that can cut both ways. And so they’re saying, Leave it to us. And the anti-abortion groups are saying: We don’t trust you. We don’t want to leave it to you. We want to let these state lawsuits move forward.
Just to very quickly go back, the Trump administration did one other thing around the March for Life as a bone to the anti-abortion community, throwing them a bone, and that is they are attempting to claw back tens of millions of dollars in covid loans that went to Planned Parenthood affiliates. A lot of these loans were already forgiven by the Biden administration, but they are trying anyways to claim there was fraud going on and to get their money back. This boils down to sort of wonky arguments of whether the specific state Planned Parenthood chapters are considered enough part of national Planned Parenthood that they can’t claim to be a small business. This is going to be a legal fight. Planned Parenthood maintains they did absolutely nothing wrong. The state affiliates are separate from the national group, but—
Rovner: Which they are, by the way.
Ollstein: They are. They are. And courts have found that they are in the past. However, the anti-abortion movement was very excited about this. They see it as the first step towards declaring all Planned Parenthoods ineligible for any government funding, something they’re calling debarment, which they’ve been pushing for for a while. So that’s one other thing to keep an eye on.
Rovner: And a reminder, many, many Planned Parenthoods don’t and never have offered abortion. Well we won’t get as far into the weeds as we could here, but if you press me, I will. All right, we’re going to take a quick break. We will be right back.
So over at the Department of Health and Human Services, we have yet another mysterious case of stopping funding and then almost immediately restarting it. Earlier this month, the Substance Abuse and Mental Health Services Administration cut off nearly $2 billion worth of grants to drug abuse and mental health providers, only to reverse that decision a day later. Now, nearly the same thing has basically happened with about $5 billion worth of grants from the Centers for Disease Control and Prevention to all 50 state health departments for things like community outreach, emergency preparedness, and disease outbreaks. According to The Washington Post, which broke , notices to states were sent out Friday and barely 12 hours later, an HHS official told the Post the funding pause, quote, “had been lifted.” Still, it apparently took several more days for states to be able to access their funding portals. You can’t help but think that at least some of this is an actual effort to destabilize the nation’s public health infrastructure, right? They can’t be that sort of disorganized that they’re going to cut off funding and put it back. There has to be a reason here. Rachel, you’re smiling.
Roubein: My colleague Lena Sun and I were hearing about this on Saturday, ahead of the big storm. State officials were trying to kind of figure out what’s going on. With the mental health grants, you saw a very kind of concerted push from the advocacy community, from Republicans and Democrats on the Hill, to push for, that was a termination of those grants, to be rescinded, and they were within about a day. This happened sort of over the weekend, and it happened very quickly. So, I can’t say what the result of sort of the change was, because the notices were dated Friday, but state officials didn’t really start getting them till on Saturday. And then we’d heard sort of midday Saturday that the temporary pause was lifted. But it definitely threw, sort of, state and local health departments that we were talking about into sort of a state of confusion trying to figure out sort of what they needed to do and by when.
Rovner: Yeah, and we have seen this repeatedly from this administration. These are sort of two dramatic cases just this month, but the stopping and starting of grant funding is making it impossible to do any planning and figure out what you can do when. It’s just, it feels like just a matter of, Let’s make it as hard as possible for these people to do their jobs.
Goldman: Yeah, and—
Rovner: By “these,” yeah, I’d say by “these people” I mean the grant recipients, not the people who are overseeing the money.
Goldman: I can’t claim to know exactly what’s going on behind the scenes, but I think, what do you expect to happen when you gut all of the administrative functions of these agencies, which is what HHS did earlier this year? And of course, some of those people have come back, but there’s a lot of instability in HHS’ rank-and-file workforce itself, and so that naturally will trickle down to their grantees.
Rovner: Right, and particularly at the CDC. Well, adding to that, elsewhere at the CDC, some key databases, mostly concerning vaccines, are not being updated. That’s according to in this week’s Annals of Internal Medicine medical journal. The study found what the authors called “unexplained pauses” in nearly half of the 82 databases they studied that are normally updated monthly. Eighty-seven percent of those databases were on vaccination-related topics. Now, this could be political. It could also be due, as Maya was just saying, to the budget and personnel cuts at CDC that we’ve talked about so much over the past year. But it does seem that we’re continuing to fly ever more blind on things like disease surveillance, right?
Goldman: Yeah, and then when you couple that with the state and local public health divisions are the ones who would be the backstop there, but if their funding is in question now, that is even more concerning for public health surveillance.
Rovner: Yeah, and of course, we are in the middle of big measles outbreaks in South Carolina and Texas and trying to watch that closely, but it’s hard to do if you only have sort of state-by-state backups to look at.
All right. Well, before we go, we need to talk about the Affordable Care Act. Remember the Affordable Care Act? Before it was subsumed by all the other headlines? Apparently, the Senate is still working on a bipartisan compromise that could restart lapsed subsidies that have spiked health insurance premiums for millions of Americans. And apparently things aren’t going all that well. And to add to it, here’s the headline on the press release for , hot off the presses just this morning — quote, “.” On the other hand, the poll did find that Republicans still trust Republicans more. And while the ACA remains pretty popular overall, it is less popular with Republicans than it was before last fall’s campaign by Republicans to blame all of the health care system’s ills on the 2010 health law. So where does that leave us? We’re with — this is the end of January. People who have been sort of reenrolled in the ACA are starting to get these huge premium notices that they may or may not be able to pay. Has Congress just kind of moved onto the next crisis?
Ollstein: So some people in Congress are still trying to resolve this crisis, even as new crises pile up. The bipartisan talks are still going on, but there is just not a lot of optimism here. There is not really agreement on lots of aspects of extending the subsidies, and all of this is really discussing, at most, sort of a one-year extension. And so they would just have to have this whole fight all over again. But yes, I would say things are looking more bleak on that front than even a few weeks ago. I don’t know what my fellow panelists think.
Rovner: And any anybody have optimism for getting these subsidies extended? I’m not seeing anybody raising their hand. Well, we will continue, obviously, to watch this space.
All right. Lastly, health insurers are starting to get the same heartburn as the pharmaceutical industry. Last week, in back-to-back hearings at the House Energy and Commerce and Ways and Means committees, the heads of five of the biggest health insurers got pretty much filleted by members of both parties. Then this week, the Trump administration kind of shocked the markets by offering a much-smaller-than-expected increase for private Medicare Advantage plans. Those have been the darlings of Republicans for a couple of decades now. Maybe Republicans do really mean it when they say they want to stop giving so much taxpayer money to health insurers?
Goldman: I was a little bit struck by how surprised everybody was at this, because I think [CMS Administrator] Dr. Mehmet Oz has been hinting that he’s much more amenable to cracking down on reported improper behavior among Medicare Advantage plans than people anticipated the next Trump administration would be. And there’s really this groundswell in the House of Representatives as well among Republicans to sort of rein in improper spending in Medicare Advantage.
Rovner: Sen. Bill Cassidy has been pretty—
Goldman: Yes.
Rovner: —outspoken on it, which surprised a lot of people. Now his, the committee that he’s the chairman of doesn’t have jurisdiction over this, but he is also a member of the Finance Committee, which does have jurisdiction over this.
Goldman: Exactly. Exactly. And so to me it wasn’t that surprising, I have to say. But it sent shock waves through the markets? Obviously, insurers are saying that if this is finalized as proposed, they’re going to have to cut benefits for seniors even more, they’re going to have to raise premiums and things like that. And of course this could be a bad political move, potentially, for Republicans. But I think—
Rovner: Because there are lots of Republican voters who are in Medicare Advantage plans—
Goldman: Absolutely.
Rovner: —and don’t want to see their benefits cut.
Goldman: Absolutely, and Medicare Advantage insurers have been saying this over and over again. The Biden administration was also pretty conservative on Medicare Advantage. I guess maybe “conservative” is a funny word choice, but—
Rovner: Light-handed.
Goldman: Yes.
Rovner: Were light-handed.
Goldman: Yes, I think, and insurers were largely able to weather that. Of course, there are some changes that they’re making this year. We’re seeing some market realignment. So it, another year of that, who knows what would happen. But I think it still remains to be seen how impactful this will actually be for beneficiaries.
Rovner: Yeah, well, another constituency to get riled up in the run-up to the midterms. All right, that is this week’s news. Now it’s time for our extra-credit segment. That’s where we each recognize the story we read this week we think that you should read, too. Don’t worry if you miss it. We’ll post the links in our show notes on your phone or other mobile device. Alice, why don’t you start us off this week?
Ollstein: Yeah. So I have this fascinating investigation from The New York Times. The headline is “.” So this is a story about these nursing home industry groups making massive donations to Trump’s super PAC and, after that, gaining a lot of access to him and using that access to lobby for the scrapping of a rule that required minimum staffing in nursing homes. And that rule was already not really being enforced, but now they are getting rid of it formally. And so I think the story does a good job of saying, Look, we can’t prove exactly that they got rid of this rule because of the donations, but it is part of a pattern where people who have given a lot of money to the president’s various groups have gotten just an incredible amount of access to him and other top officials. And the story also stresses why we should care about all of this. There’s just been a lot of horrific data coming out of nursing homes of problems caused by understaffing, patients experiencing preventable injuries, infections and other health problems that go unnoticed until it’s too late or it gets way more serious, and even facilities using, basically drugging patients to keep them easy to control and complacent, because there just isn’t enough staff to attend to them. People who have dementia and other things need a lot of care and can get upset and disoriented. And instead of taking care of them, they’re putting them on heavy psychotropic drugs. And so it’s a really sad and serious situation, and this article shows some potential pay to play.
Rovner: Yeah, I tend to be, in general, skeptical of administrations doing things that we thought they were going to do anyway and someone else happened to give them money. But this draws a pretty clear line. They did do what they were going to do anyway, which was going to sort of not really enforce these regulations. Anyway it’s really good story. Should read it. Maya.
Goldman: My extra credit this week is “,”on NBC News by Berkeley Lovelace Jr. And it’s one of those stories that, wow, I wish I had written this. It’s a really great explanation of one of the sort of lesser-talked-about side effects of losing enhanced ACA subsidies, which is that people are going into plans that are — they’re still opting to be in insurance, but they’re taking plans that are lower premiums but much higher deductibles, which means that their coverage is less valuable. And they might still have to pay a lot of money out-of-pocket for most services, and then they might not seek those services, which sort of negates the purpose of having health insurance and its effect on public health. And this story shows that Kentucky, Idaho, Massachusetts, New York, Virginia, Rhode Island, California are all seeing decreases in “silver” plan enrollment, which is sort of that lower-deductible, higher-premium tier, and increases in “bronze” enrollment, which is super-high-deductible. So huge thing to watch.
Rovner: Really, really good explanation. Rachel.
Roubein: My extra credit is by Stat News. The headline is “,” by O. Rose Broderick. And the story lays out how the Department of Health and Human Services yesterday, on Wednesday, announced the appointment of new members to a federal committee that will advise Secretary [Robert F.] Kennedy [Jr.] on autism. Broderick reports that many of the new members of the committee, which is called the Interagency Autism Coordinating Committee, have publicly expressed or belonged to groups that have publicly expressed a belief in the debunked claim that vaccines can cause autism. Stat had earlier this week that the members of the committee had met in secret and that some members of the kind of broader autism community were worried about the panel. And just kind of for sort of the big-picture point of view, Kennedy, last year, pledged to find the causes of autism. And during his tenure as HHS secretary, he’s challenged years of public health messaging on vaccines, such as instructing the CDC to contradict the long-settled scientific conclusion that vaccines do not cause autism. Kennedy, in a press release yesterday, called the researchers “the most qualified experts — leaders with decades of experience studying, researching, and treating autism.”
Rovner: Yet another piece of this. There’s a lot of advisory committees at HHS, and there are many of them worth keeping a close eye on. All right, my extra credit this week is from Science magazine, by Monica Hersher and Jeffrey Mervis. It’s called “,” and it puts some actual numbers to the science brain drain that we’ve been talking about. The authors looked at 14 agencies across the federal government, including the NIH [National Institutes of Health], FDA, and CDC at HHS. They noted that those 10,000-plus experts represented only 3% of the more than 300,000 federal workers who’ve left employment since Trump took office, but they represent 14% of the total number of Ph.D.s in science, technology, engineering, math, and health fields. Most quit or retired after taking buyouts rather than being fired, according to the data. But as the authors noted, quote, “these departing Ph.D.s took with them a wealth of subject matter expertise and knowledge about how these agencies operate.” Certainly a win for the Trump administration, which wants to remake the federal government’s approach to science. For the rest of us, we will have to wait and see.
OK, that’s this week’s show. Before we go, a reminder that our annual Â鶹ŮÓÅ Health Policy Valentine contest is open. We want to see your clever, heartfelt, or hilarious tributes to the policies that shape health care. Submit your poem, whether conventional, free-form, or haiku, by noon Eastern on Wednesday, Feb. 4. The winning poem will receive a custom comic illustration in the Morning Briefing on Feb. 13. I will post a link to the formal announcement in our show notes.
As always, thanks to our editor, Emmarie Huetteman, and our producer-engineer, Francis Ying. A reminder: What the Health? is now available on WAMU platforms, the NPR app, and wherever you get your podcasts, as well as, of course, kffhealthnews.org. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org, or you can still find me on X, , or on Bluesky, . Where are you folks these days? Maya?
Goldman: You can find me on under my name or on X, .
Rovner: Alice.
Ollstein: Still on X, , and on Bluesky, .
Rovner: Rachel.
Roubein: under my name. Bluesky, . X, .
Rovner: We will be back in your feed next week. Until then, be healthy.
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<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2148643&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>But some health policy experts say the plan could help reduce billions of dollars in overcharges that have been common in the program for more than a decade.
On Jan. 26, Centers for Medicare & Medicaid Services officials announced they planned to raise rates paid to health plans by for 2027, far less than the industry expected. Some of the largest, publicly traded insurers, such as UnitedHealth Group and Humana, saw their as a result, while industry groups threatened that people 65 and older could see service cuts if the government didn’t kick in more money.
In Medicare Advantage, the federal government pays private insurance companies to manage health care for people who are 65 and older or disabled. But less noticed in the brouhaha over rates: CMS also proposed restricting plans from conducting what are called “chart reviews” of their customers. These reviews can result in new medical diagnoses, sometimes including conditions patients haven’t even asked their doctors to treat, that increase government payments to Medicare Advantage plans.
The practice has been criticized for more than a decade by government auditors who say it has triggered billions of dollars in overpayments to the health plans. Earlier this month, the Justice Department announced a record $556 million settlement with the nonprofit health system Kaiser Permanente over allegations the company added about half a million diagnoses to its Advantage patients’ charts from 2009 to 2018, generating about $1 billion in improper payments.
KP did not admit any wrongdoing as part of the settlement.
“I do think the administration is serious about cracking down on overpayments,” said Spencer Perlman, a health care policy analyst in Bethesda, Maryland.
Perlman said that while the Trump administration strongly supports Medicare Advantage, officials are “troubled” by plans that rake in undue profits by using chart reviews to bill the government for medical conditions even when no treatment was provided.
In a , CMS Administrator Mehmet Oz said curbing this practice would ensure more accurate payments to the plans while “protecting taxpayers from unnecessary spending that is not oriented towards addressing real health needs.”
“These proposed payment policies are about making sure Medicare Advantage works better for the people it serves,” Oz said.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, called the proposal “at least a mildly encouraging sign,” though he said he suspected health plans might eventually find a way around it.
Kronick has argued that switching seniors to Medicare Advantage plans has cost taxpayers tens of billions of dollars more than keeping them in the government-run Medicare program, because of unbridled medical coding excesses. The insurance plans have grown dramatically in recent years and now enroll , or more than half of people eligible for Medicare.
David Meyers, an associate professor at the Brown University School of Public Health, called the proposed restriction on chart reviews “a step in the right direction.”
“I think the administration has been signaling pretty strongly they want to cut back on inefficiencies,” he said.
The outcry from industry, mostly directed at the proposal to essentially hold Medicare Advantage payment rates flat, was quick and sharp.
“If finalized, this proposal could result in benefit cuts and higher costs for 35 million seniors and people with disabilities when they renew their Medicare Advantage coverage in October 2026,” said Chris Bond, a spokesperson for AHIP, formerly known as America’s Health Insurance Plans.
CMS is accepting public comments on the proposal and says it will issue a final decision on the payment rates and other provisions by early April.
Meyers said health plans often claim they will be forced to slash benefits when they aren’t satisfied with CMS payments. But that rarely happens, he said.
“The plans can still make money,” he said. “They mostly are very profitable, just not as profitable as shareholders expected.”
The government pays Medicare Advantage plans higher rates to cover sicker patients. But over the past decade, dozens of whistleblower lawsuits, government audits, and have alleged that health plans exaggerate how sick their customers are to pocket payments they don’t deserve, a tactic known in the industry as “upcoding.”
Many Medicare Advantage health plans have hired medical coding and analytics consultants to review patients’ medical charts to find new diagnoses that they then bill to the government. Medicare rules require that health plans document — and treat — all medical conditions they bill.
Yet federal audits have shown for years that many health plans’ billing practices don’t hold up to scrutiny.
A by the Department of Health and Human Services inspector general found that the health plans “almost always” used chart reviews to add, rather than delete, diagnoses. “Over 99 percent of chart reviews in our review added diagnoses,” investigators said.
The report found that diagnoses reported only on chart reviews — and not on any service records — resulted in an estimated $6.7 billion in payments for 2017.
This week’s proposal is not the first time CMS has tried to crack down on chart reviews.
In January 2014, federal officials drafted a plan to restrict the practice, only to abruptly back off a few months later amid what one agency official described as an “uproar” from the industry.
The health insurance industry has for years relied on aggressive lobbying and public relations campaigns to fight efforts to rein in overpayments or otherwise reduce taxpayers’ costs for Medicare Advantage.
What happens this time will say a lot about whether the Trump administration is serious about cracking down on controversial, long-standing payment practices in the program.
Perlman, the policy analyst, said it is “quite common” for CMS to partially backtrack when faced with opposition from the industry, such as by phasing in changes over several years to soften the blow on health plans.
David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said finalizing the chart review proposal “would be a meaningful step towards reining in overpayments to Medicare Advantage plans.”
But in the past, he said, even a minor change to Advantage payments has led the industry to protest that “the sky will fall as a result, and the proposal is usually dropped.”
“It’s hard to tell at this stage how this will play out,” Lipschutz said.
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<img id="republication-tracker-tool-source" src="/?republication-pixel=true&post=2149100&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">]]>But two years ago, he heard about Peak Health, a new Advantage plan started by the West Virginia University Health System, where his doctors practice. It was cheaper and offered more personal attention, plus extras such as an allowance for over-the-counter pharmacy items. Those benefits are more important than ever, he said, as he’s treated for cancer.
“I decided to give it a shot,” said Wilkewitz, 79. “If I didn’t like it, I could go back to Humana or whatever after a year.”
He’s sticking with Peak Health. Members of Medicare Advantage plans, a privately run alternative to the government’s Medicare program, can change plans through the end of March.
Now entering its third year, Peak Health has tripled its enrollment since last year, to “north of 10,000,” said Amos Ross, its president. It expanded from 20 counties to 49, he said, and moved into parts of western Pennsylvania for the first time.
Although hospital-owned plans are only a sliver of the Medicare Advantage market, their enrollment continues to grow, reflecting the overall increase in Advantage members. Of the 62.8 million Medicare beneficiaries eligible to join Advantage plans, , according to Â鶹ŮÓÅ, the health information nonprofit that includes Â鶹ŮÓÅ Health News. While the number of Advantage plans owned by hospital systems is relatively stable, Mass General Brigham in Boston and others are expanding their service areas and types of plan offerings.
Health systems have dabbled in the insurance business for years, but it’s not for everyone. MedStar Health, serving the greater Washington, D.C., area, said it closed its Medicare Advantage plan at the end of 2018, citing financial losses.
“It’s a ton of work,” said Ross, who spent more than a decade in the commercial health insurance industry.
Like any other health insurer, hospitals entering the business need a back-office infrastructure to enroll patients, sign up providers, fill prescriptions, process claims, hire staff, and — most importantly — assure state regulators they have a reserve of money to pay claims. Once they get a state insurance license, they need approval from the federal Centers for Medicare & Medicaid Services to sell Medicare Advantage policies. Some systems affiliate with or create an insurance subsidiary, and others do most of the job themselves.
Kaiser Permanente, the nation’s largest nonprofit health system by revenue, started an experimental Medicare plan in 1981 and now has nearly 2 million people enrolled in dozens of Advantage plans in eight states and the District of Columbia. The Justice Department announced Jan. 14 that KP had agreed to pay $556 million to settle accusations that its Advantage plans fraudulently billed the government for about $1 billion over a nine-year period.
Last year, UCLA Health introduced two Medicare Advantage plans in Los Angeles County, the most populous county in the United States. Other new hospital-owned plans have cropped up in less profitable rural areas.
“These are communities that have been very hard for insurers to move into,” said Molly Smith, group vice president for public policy at the American Hospital Association.
But Advantage plans offered by hospitals have a familiar, trusted name. They don’t have to move into town, because their owners — the hospitals — never left.
Bad Breakups
Medicare Advantage plans usually restrict their members to a network of doctors, hospitals, and other clinicians that have contracts with the plans to serve them. But if hospitals and plans can’t agree to renew those contracts, or when disputes flare up — often spurred by payment delays, denials, or burdensome prior authorization rules — the health care providers can drop out.
These breakups, plus planned terminations and service area cuts, forced more than 3.7 million Medicare Advantage enrollees to make a tough choice last year: find new insurance for 2026 that their doctors accept or, if possible, keep their plan but find new doctors.
About 1 million of these stranded patients had coverage from UnitedHealthcare, the country’s largest health insurer. In a July earnings update for financial analysts, chief financial officer John Rex blamed the company’s retreat on hospitals, where “most encounters are intensifying in services and costing more.”
The turbulence in the commercial insurance market has upset patients as well as their providers. Sometimes contract disputes have been fought out in the open, with anxious patients in the middle receiving warnings from each side blaming the other for the imminent end to coverage.
When Fred Neary, 88, learned his doctors in the Baylor Scott & White Health system in central and northern Texas would be leaving his Medicare Advantage plan, he was afraid the same thing could happen again if he joined a plan from another commercial insurer. Then he discovered that the 53-hospital system had its own Medicare Advantage plan. He enrolled in 2025 and is keeping the plan this year.
“It was very important to me that I would never have to worry about switching over to another plan because they would not accept my Baylor Scott & White doctors,” he said.
Eugene Rich, a senior fellow at Mathematica, a health policy research group, said hospital systems’ Medicare Advantage plans offer “a lot of stability for patients.”
“You’re not suddenly going to discover that your primary care physician or your cardiologist are no longer in the plan,” he said.
A that Rich co-authored in July found that enrollment in Advantage plans owned by hospital systems grew faster than traditional Medicare enrollment for the first time in 2023, though not as rapidly as the overall rise in sign-ups for all Advantage plans.
The massive UCLA Health system introduced its two Medicare Advantage plans in Los Angeles County in January 2025, even though patients already had a list of more than 70 Advantage plans to choose from. Before rolling out the plan, the University of California Board of Regents discussed its merits at a November 2024 meeting. The offer rare insight into a conversation that private hospital systems would usually hold behind closed doors.
“As increasing numbers of Medicare-enrolled patients turn to new Medicare Advantage plans, UC Health’s experience with these new plans has not been good, either for patients or providers,” the minutes read, summarizing comments by David Rubin, executive vice president of UC Health.
The minutes also describe comments from Jonathon Arrington, CFO of UCLA Health. “Over the years, in order to care for Medicare Advantage patients, UCLA has entered numerous contracts with other payers, and these contracts have generally not worked out well,” the minutes read. “Every two or three years, UCLA has found itself terminating a contract and signing a new one. Patients have remained loyal to UCLA, some going through three iterations of cancelled contracts in order to remain with UCLA Health.”
Costs to Taxpayers
CMS pays Advantage plans a monthly fixed amount to care for each enrollee based on the member’s health condition and location. In 2024, the federal government paid Advantage plans an estimated $494 billion to care for patients, according to the Medicare Payment Advisory Commission, which monitors the program for Congress.
The commission said this month that it projects insurers in 2026 will be paid 14%, or about $76 billion, more than it would have cost government-run Medicare to care for similar patients.
Many Democratic lawmakers have criticized overpayments to Medicare Advantage insurers, though the program has bipartisan congressional support because of its increasing popularity with Medicare beneficiaries, who are often attracted by dental care and other coverage unavailable through traditional Medicare.
Whenever Congress threatens cuts, insurers claim these generous federal payments are essential to keep Medicare Advantage plans afloat. UCLA Health’s Advantage plans will need at least 15,000 members to be financially sustainable, according to the meeting minutes. CMS data indicates that 7,337 patients signed up in 2025.
A study in August compared patients in commercial Medicare Advantage who had major surgery with those covered by Medicare Advantage plans owned by their hospital. The latter group had fewer complications, said co-author Thomas Tsai, an associate professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.
Smith, of the American Hospital Association, isn’t surprised. When insurers and hospitals are not on opposite sides, she said, care delivery can be smoother. “There’s more flexibility to manage premium dollars to cover services that maybe wouldn’t otherwise be covered,” Smith said.
But Tsai warns seniors that hospital-owned Medicare Advantage plans operate under the same rules as those run by commercial health insurance companies. He said patients should consider whether the extra benefits of Advantage plans “are worth the trade-off of potentially narrow provider networks and more utilization management than they would get from traditional Medicare.”
In Texas, Neary hopes the closer relationship between his doctors and his insurance plan means there’s less of a chance that bills for his medical care will be kicked back.
“I don’t think I would run into a situation where they would not provide coverage if one of their own doctors recommended something,” he said.
Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .This <a target="_blank" href="/medicare/health-insurance-medicare-advantage-plans-hospitals/">article</a> first appeared on <a target="_blank" href="">Â鶹ŮÓÅ Health News</a> and is republished here under a <a target="_blank" href=" Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
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