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Tag: Medicare

  • Trump vows ‘we will always protect Social Security, Medicare, Medicaid,’ but his signature tax cut shortened their lifespans | Fortune

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    In his State of the Union address, President Donald Trump proudly proclaimed to members of Congress and the public that the United States is “bigger, better, richer and stronger than ever before,” touting the benefits of his signature tax policy in particular, the One Big Beautiful Bill Act (OBBBA). He also claimed that his administration is working to make it easier for Americans to save for retirement. “Under this administration,” he said, “we will always protect Social Security and Medicare … We will always protect Social Security, Medicare, Medicaid.”

    But both things cannot be true.

    Despite Trump’s ongoing pledges to protect the nation’s vital social safety nets, recent economic projections reveal a starkly different reality. Sweeping legislative changes spearheaded by his administration have drastically shortened the financial lifespans of both Medicare and Social Security, accelerating their paths toward insolvency.

    For decades, surplus payroll tax revenue was socked away in trust funds, which were designed to be tapped when revenue was no longer sufficient to cover benefits.

    According to a newly updated report from the Congressional Budget Office (CBO), recent policy shifts have erased 12 years of projected solvency from the Hospital Insurance (HI) Trust Fund, which pays for Medicare Part A. The fund is now expected to be entirely exhausted by 2040, rather than 2052, as projected in March 2025. The primary culprit behind this rapid financial deterioration is the OBBBA into law, lowering tax rates and creating a temporary deduction for taxpayers aged 65 and older. While politically popular, these tax cuts significantly starved the trust fund of the revenues it normally receives from taxing Social Security benefits.

    The HI Trust Fund serves as the financial backbone for essential health services, including inpatient hospital care, skilled nursing facility stays, home health care, and hospice care. If that fund is exhausted in 2040, Medicare would be legally restricted to paying out only what it collects in revenue, triggering automatic benefit cuts. The CBO estimates these reductions would begin at an 8% cut in 2040 and steadily climb to a 10% cut by 2056.

    Meanwhile, Social Security faces a similarly accelerated timeline toward crisis. The CBO estimates that the Social Security trust fund will run out of money even sooner, by fiscal year 2032, which begins in October 2031. If Congress fails to intervene before this insolvency date, benefits would be strictly limited to incoming revenue. The Committee for a Responsible Federal Budget estimates that a typical couple turning 60 today would face a devastating $18,400 annual cut to their retirement benefits when the fund runs dry.

    Trump laid into Democrats for voting against OBBBA, which he called “these really important and very necessary massive tax cuts. They wanted large-scale tax increases to hurt the people instead. But we held strong and with the great Big Beautiful Bill we gave you no tax on tips, no tax on overtime, and no tax on Social Security for our great country.”

    Reducing tax revenue for these programs, though, is hastening their looming fiscal crisis. Alongside lower projected payroll tax revenues, this policy shift enacted during the Trump administration has starved the safety net of critical future funding.

    Cuts to come in the future?

    Once the trust funds are exhausted, additional money must be found somewhere or else benefits must be slashed. Another source is discretionary money.

    But Bernard Yaros, lead U.S. economist at Oxford Economics, has warned that funding Social Security and Medicare with general revenue could trigger a negative reaction in the bond market, sparking a sustained increase in interest rates, ultimately forcing lawmakers to make painful, drastic cuts to nondiscretionary programs to head off a full-blown fiscal crisis.

    Faced with these looming cliffs, lawmakers may be tempted to simply finance the shortfalls with more national debt rather than making tough political choices to hike taxes or reduce benefits. However, economists warn this could spark a severe financial crisis. Veronique de Rugy, a senior research fellow at the Mercatus Center, cautioned in a Creators Syndicate op-ed that financial markets will quickly account for the additional borrowing.

    “Inflation may not wait for debt to pile up,” de Rugy warned, noting it could “arrive the moment Congress commits to that debt-ridden path”.

    Addressing this looming shortfall will require significant legislative action. To restore the 12 years of lost Medicare solvency alone, lawmakers will be forced to increase taxes, slash health care payments, or implement a politically fraught combination of these approaches—eventually. That flies directly in the face of the politically popular tax cuts that Trump hailed as so significant, on the year of the United States’ 250th birthday.

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    Nick Lichtenberg

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  • Is UnitedHealth a safe dividend stock after Medicare shock?

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    Wall Street just learned an expensive lesson about betting on Washington.

    According to a Wall Street Journal report, UnitedHealth Group lost roughly $60 billion in market value on January 27 after the Centers for Medicare & Medicaid Services proposed 2027 payment rates that would barely budge from current levels.

    Analysts had expected increases closer to 5%. Instead, CMS suggested a 0.09% bump. UNH stock plunged 19% in a single session, marking its worst day since April 2025.

    For income investors who’ve collected UnitedHealth (UNH) dividends through thick and thin, the question isn’t just about recovering the stock price.

    It’s whether that dividend check keeps showing up while the company navigates what could be its roughest period in decades.

    UNH is dependent on Medicare for long-term growthGetty Images Heather Diehl · Getty Images Heather Diehl

    Here’s the uncomfortable truth:

    • UnitedHealth has become heavily dependent on Medicare for revenue growth.

    • The company’s Medicare revenue is now more than double its private insurance revenue.

    • That worked great when government rates kept climbing. Now it’s a vulnerability.

    CEO Steve Hemsley, who came out of retirement to lead the turnaround after the company fired his predecessor last year, tried to project confidence during Tuesday’s earnings call.

    Hemsley said:

    Investors didn’t share his enthusiasm as the stock kept falling.

    UnitedHealth now expects 2026 revenue to reach roughly $439 billion, a 2% decline from 2025. That’s the first revenue contraction since 1989, back when hardly anyone had heard of managed care.

    The company squeaked past fourth-quarter earnings estimates by a penny, reporting adjusted EPS of $2.11. But those results excluded a massive $1.6 billion after-tax charge tied to the Change Healthcare cyberattack and restructuring costs.

    Tim Noel, who runs UnitedHealth’s insurance operations, delivered some sobering projections on membership.

    Medicare Advantage alone will shed between 1.3 million and 1.4 million members this year.

    Related: The 10 drugs driving Medicare’s biggest prescription costs

    That’s worse than the company originally anticipated, driven by fierce competition during the annual enrollment period.

    Add in expected losses of 565,000 to 715,000 Medicaid members, plus declines across commercial plans, and you’re looking at total membership dropping by 2.3 million to 2.8 million people.

    That’s not all bad news, though. UnitedHealth deliberately walked away from unprofitable business, repricing plans to focus on members it can actually serve sustainably. The strategy prioritizes margin recovery over top-line growth.

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  • More Americans will die than be born in 2030, CBO predicts—leaving immigrants as the only source of population growth | Fortune

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    For the first time in modern history, the United States is on the brink of losing its most basic engine of growth: more births than deaths.

    According to the Congressional Budget Office’s (CBO) Demographic Outlook, released Tuesday, the year 2030 marks a tipping point that will fundamentally reshape the  economy and social fabric. That’s the year the “natural” U.S. population—the balance of births over deaths—is projected to vanish. 

    “Net immigration (the number of people who migrate to the United States minus the number who leave) is projected to become an increasingly important source of population growth in the coming years, as declining fertility rates cause the annual number of deaths to exceed the annual number of births starting in 2030,” the CBO writes. “Without immigration, the population would begin to shrink in 2030.”

    From that point on, every additional person added to the U.S. population will come from immigration, a demographic milestone once associated with aging countries like Italy and Japan. 

    The shift is striking not only for what it says about America’s rapidly aging society, but also for how soon it is expected to arrive. Just a year ago, many demographic forecasts—including the CBO’s own forecast—placed this crossover well into the late 2030s or even the 2040s. The updated outlook from CBO moves the timeline forward by nearly a decade.

    This rapid acceleration, the CBO said, is driven by the “double squeeze” of declining fertility and an aging populace, combined with recent policy shifts on immigration. CBO analysts have drastically lowered their expectations for the total fertiility rate, now projecting it to settle at just 1.53 births per woman — well below the 2.1 “replacement rate” needed for a stable population. At the same time, the massive “Baby Boomer” generation is reaching ages with higher mortality rates, causing annual deaths to climb.

    The timeline further compressed following the passage of the 2025 Reconciliation Act, which increased funding for more ICE agents and immigration judges to process cases faster, resulting in approximately 50,000 immigrants in detention daily through 2029, CBO said. The office calculated that these provisions will result in roughly 320,000 fewer people in the U.S. population by 2035 than previously estimated.

    The new projections show that U.S. population growth will steadily decelerate over the next three decades until it finally hits zero in 2056. For most of the 20th century, the population grew at close to 1% a year: a flat population would represent a historic break from that norm. 

    The economic consequences of this shift are hard to overstate. While the number of retirees swells, the pool of workers funding the social safety net — and caring for the aging population —  is narrowing. Americans aged 65 and older are the fastest-growing segment of the population, pushing the “old-age dependency ratio” sharply higher. In 1960, there were about five workers for every retiree. Today, that ratio is closer to three-to-one. By the mid-2050s, the CBO projects it will fall to roughly two workers per retiree. The contraction will have “significant implications” on the federal budget, including outsized effects on Social Security and Medicare, placing pressure on those trust funds which rely on a robust base of payroll taxes that a stagnant population cannot easily provide.

    Further, because national GDP is essentially the product of the number of workers multiplied by their individual productivity, the loss of labor force growth means the American economy will have to rely almost entirely on technological breakthroughs and AI to drive future gains. This may be happening ahead of schedule, as continued weak employment growth in December showed a “jobless expansion,” in the words of KPMG chief economist Diane Swonk, as Fortune previously reported.

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    Eva Roytburg

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  • Health coverage at risk as expanded ACA subsidies lapse nationwide

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    NEW YORK CITY, New York: Millions of Americans are beginning 2026 facing sharply higher health insurance bills after enhanced Affordable Care Act subsidies expired, locking in premium increases that could force some households to drop coverage altogether.

    The tax credits, first introduced during the COVID-19 pandemic and later extended by Democrats, had lowered insurance costs for most people who buy coverage on the Affordable Care Act marketplaces. Their expiration comes after months of political deadlock in Washington, despite warnings from both parties that the issue could carry significant electoral consequences.

    Democrats pushed unsuccessfully to extend the subsidies, even triggering a 43-day government shutdown over the issue. Some moderate Republicans urged action, while President Donald Trump floated — then abandoned — a potential compromise after opposition from conservative allies. With no agreement reached before the deadline, the credits expired at the start of the new year.

    A House vote expected later in January could reopen the debate, but there is no guarantee that lawmakers will succeed in restoring the subsidies.

    The lapse affects millions of Americans who do not receive health insurance through an employer and are ineligible for Medicaid or Medicare — including self-employed workers, small business owners, farmers, and ranchers. The timing also coincides with a midterm election year in which affordability, particularly healthcare costs, ranks among voters’ top concerns.

    “It really bothers me that the middle class has moved from a squeeze to a full suffocation, and they continue just to pile on and leave it up to us,” said Katelin Provost, a 37-year-old single mother whose premiums are set to soar. “I’m incredibly disappointed that there hasn’t been more action.”

    Costs Jump Sharply for Many Households

    The expanded subsidies, introduced in 2021, allowed some lower-income enrollees to obtain coverage with no monthly premium, capped costs for higher earners at 8.5 percent of income, and broadened eligibility for middle-class households. Democrats later extended the program through the end of 2025.

    With those credits gone, the impact is substantial. On average, more than 20 million subsidized Affordable Care Act enrollees are seeing premium increases of 114 percent in 2026, according to an analysis by KFF.

    The higher premiums come amid broader increases in U.S. healthcare costs, which are also pushing up deductibles and other out-of-pocket expenses.

    Some enrollees are absorbing the added burden. Stan Clawson, a 49-year-old freelance filmmaker and adjunct professor in Salt Lake City, said his monthly premium will rise from just under US$350 to nearly $500. Clawson, who lives with paralysis from a spinal cord injury, said the increase is painful but unavoidable.

    Others face far steeper hikes. The Provost said her premium is jumping from $85 a month to nearly $750.

    Enrollment Fallout Still Uncertain

    Health policy experts warn that higher premiums could lead many people — particularly younger and healthier enrollees — to abandon coverage, raising costs further for those who remain insured.

    An analysis by the Urban Institute and the Commonwealth Fund last September projected that about 4.8 million Americans could lose coverage in 2026 due to the expiration of subsidies.

    However, enrollment effects remain uncertain, as the deadline to select or change plans runs through Jan. 15 in most states.

    Provost said she is hoping Congress revives the subsidies early this year. If not, she plans to drop her own coverage and keep insurance only for her four-year-old daughter.

    Political Stalemate Continues

    In December, the Senate rejected competing partisan proposals — a Democratic plan to extend the subsidies for three years and a Republican alternative centered on health savings accounts. In the House, four centrist Republicans joined Democrats to push for a vote on a three-year extension, though prospects for passage remain unclear.

    For many Americans, the impasse feels detached from everyday realities.

    “Both Republicans and Democrats have been saying for years, oh, we need to fix it. Then do it,” said Chad Bruns, a 58-year-old Affordable Care Act enrollee in Wisconsin. “They need to get to the root cause, and no political party ever does that.”

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  • Trump announces lower drug price deals with 9 pharmaceutical companies

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    U.S. President Donald Trump announced Friday that nine drugmakers have agreed to lower the cost of their prescription drugs in the U.S.

    Pharmaceutical companies Amgen, Bristol Myers Squibb, Boehringer Ingelheim, Genentech, Gilead Sciences, GSK, Merck, Novartis and Sanofi will now rein in Medicaid drug prices to match what they charged in other developed countries.

    As part of the deal, new drugs made by those companies will also be charged at the so-called “most-favored-nation” pricing across the country on any newly launched medications for all, including commercial and cash pay markets as well as Medicare and Medicaid.

    Drug prices for patients in the U.S. can depend on a number of factors, including the competition a treatment faces and insurance coverage. Most people have coverage through work, the individual insurance market or government programs like Medicaid and Medicare, which shield them from much of the cost.

    Patients in Medicaid, the state and federally funded program for people with low incomes, already pay a nominal co-payment of a few dollars to fill their prescriptions, but lower prices could help state budgets that fund the programs.

    Lower drug prices also will help patients who have no insurance coverage and little leverage to negotiate better deals on what they pay. But even steep discounts of 50% found through the administration’s website could still leave patients paying hundreds of dollars a month for some prescriptions.

    William Padula, a pharmaceutical and health economics professor at USC, said Medicaid already has the most favorable drug rates which in some cases will be close to what the “most-favored-nation” price is so it remains to be seen what other impacts it could have, such as more research and development.

    “It can’t be bad. I don’t see much downside but it’s hard to judge what the upside is,” Padula said.

    And while it is significant that Trump was able to get big drugmakers to the table to negotiate lower prices, it will take years to gage how effective this initiative is in terms of more people obtaining more of the medicines they need.

    “It’s good for their stock and it’s good for their future” research and development, Padula said of the pharmaceutical companies. “It’s clearly influential but will all this add up to a major effect? Nothing really matters here unless our health gets better as a country.”

    Trump administration officials said the drugmakers will also sell pharmacy-ready medicines on the TrumpRx platform, which is set to launch in January and will allow people to buy drugs directly from manufacturers.

    Companies such as Merck, GSK and Bristol Myers Squibb also agreed to donate significant supplies of active pharmaceutical ingredients to a national reserve and to formulate and distribute them into medications such as antibiotics, rescue inhalers and blood thinners as needed in an emergency.

    The New Jersey-based Bristol Myers Squibb further announced that it will be giving for free to the Medicaid program its signature blood thinner prescribed to reduce the risk of blood clots and stroke. Known as Eliquis, it is the company’s top prescribed drug as well as being one of Medicaid’s most widely-used medicines.

    Padula said the donations — which encompass some of the world’s most critical medicines — are a significant step toward health equity and an acknowledgement that the drugmakers can afford to seek profits elsewhere in their operations. Eliquis already has been one of the most profitable drugs ever made.

    “It’s a thoughtful health equity move that they can afford given that it’s been such a blockbuster,” Padula said of the Eliquis donation.

    Other major drugmakers including Pfizer, AstraZeneca, EMD Serono, Novo Nordisk and Eli Lilly struck similar deals with the Trump administration earlier this year.

    Though individual terms were not disclosed, the administration has now negotiated lower drug prices with 14 companies since Trump publicly sent letters to executives at 17 pharmaceutical companies about the issue, noting that U.S. prices for brand-name drugs can be up to three times higher than averages elsewhere.

    Trump said he effectively threatened the pharmaceutical companies with 10% tariffs to get them to “do the right thing.”

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  • Trump administration says lower prices for 15 Medicare drugs will save taxpayers billions

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    NEW YORK — Pharmaceutical companies have agreed to slash the Medicare prices for 15 prescription drugs after months of negotiations, reductions that are expected to produce billions in savings for taxpayers and older adults, the Trump administration said.

    But the net prices it unveiled for a 30-day supply of each drug are not what Medicare recipients will pay at their pharmacy counters, since those final amounts will depend on each individual’s plan and how much they spend on prescriptions in a given year.

    Health Secretary Robert F. Kennedy Jr. touted the deals as part of the administration’s efforts to address affordability concerns among Americans. The Medicare drug negotiation program that made them possible is mandated by law and began under President Joe Biden’s administration.

    “President Trump directed us to stop at nothing to lower health care costs for the American people,” Kennedy said in a statement Tuesday evening. “As we work to Make America Healthy Again, we will use every tool at our disposal to deliver affordable health care to seniors.”

    The announcement marks the completion of a second round of negotiations under a 2022 law that allows Medicare to haggle over the price it pays on the most popular and expensive prescription drugs used by older Americans, bringing the total number of negotiated drug prices to 25. The new round of negotiated prices will go into effect in 2027. Reduced prices for the inaugural round of 10 drugs negotiated by the Biden administration last year will go into effect in January.

    The latest negotiated prices apply to some of the prescription medications on which Medicare spends the most money, including the massively popular GLP-1 weight-loss and diabetes drugs Ozempic, Rybelsus and Wegovy. Some of the other drugs involved in the negotiations include Trelegy Ellipta, which treats asthma; Otezla, a psoriatic arthritis drug; and various drugs that treat diabetes, irritable bowel syndrome and different forms of cancer.

    Dr. Mehmet Oz, Centers for Medicare and Medicaid Services administrator, said the administration delivered “substantially better outcomes for taxpayers and seniors in the Medicare Part D program” than the previous year’s deals.

    Under the first round of Medicare price negotiations, the Biden administration said the program would have saved about $6 billion on net covered prescription drug costs, or about 22%, if it had been in effect the previous year. The Trump administration said its latest round would have saved the government about $8.5 billion in net spending, or 36%, if it had been in effect last year.

    It’s unclear exactly how much money the newly announced deals could save Medicare beneficiaries when they are buying prescription drugs at the pharmacy because those costs are determined by various individual factors.

    A new rule that kicked off this year also caps out-of-pocket drug costs for Medicare beneficiaries at $2,000, giving some relief to older adults affected by high-cost prescriptions. The administration said estimated out-of-pocket savings for Medicare beneficiaries with drug plans is about $685 million.

    Spencer Perlman, director of health care research at Veda Partners, said the Trump administration’s improved outcomes probably resulted from the mix of drugs being negotiated and lessons learned from the first year of negotiations.

    Net drug prices are proprietary, he said, but “if we take the administration at their word, I think it demonstrates that they have secured meaningful price concessions for seniors, meaning the Medicare Drug Price Negotiation Program is working as intended.”

    The GLP-1 weight-loss drugs that were part of the negotiations have been especially scrutinized for their high out-of-pocket costs. Yet it’s still unclear to what extent Medicare beneficiaries who want to use the drugs to treat obesity will be able to do so.

    Medicare has long been prohibited from paying for weight-loss treatments, but a separate deal recently announced between the Trump administration and two pharmaceutical companies included plans for a pilot program that will expand coverage for the drugs to additional high-risk obese and overweight people.

    The Trump administration this year has also negotiated several unrelated deals with drug companies to lower the cost of their products for the wider population.

    Pharmaceutical companies, meanwhile, have sued over the Medicare drug negotiations enabled by the 2022 Inflation Reduction Act and remain opposed to them.

    “Whether it is the IRA or MFN, government price setting for medicines is the wrong policy for America,” Alex Schriver, senior vice president of public affairs at the Pharmaceutical Research and Manufacturers of America, or PhRMA, said in a statement. “These flawed policies also threaten future medical innovation by siphoning $300 billion from biopharmaceutical research, undermining the American economy and our ability to compete globally.”

    Next year, Medicare will negotiate prices for another round of 15 drugs, including physician-administered drugs for the first time.

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  • Medicare negotiates lower prices on 15 popular medications. Will it save you money?

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    The Trump administration has negotiated lower prices for 15 widely used medications covered by Medicare, with the federal government saying the effort will cut spending on those drugs by 44%, or about $12 billion. So will the initiative help save money for seniors?

    That’s less clear, given that Medicare enrollees are already protected by a cap on drug costs. The Centers for Medicare and Medicaid Services (CMS) said Monday the new prices will save the 55 million people enrolled in the Part D pharmaceutical plan a total of about $685 million.

    That equates to average savings of about $12.45 per Medicare participant, although an individual’s out-of-pocket reductions will be based on whether they use one or more of the drugs covered by the new agreement and if they’ve reached their annual spending cap. 

    CMS didn’t immediately respond to a request for comment about the projected individual savings under the new Medicare pricing plan. 

    The lower drug prices were arranged through the Inflation Reduction Act, which included a measure to negotiate prices for some of Medicare’s most expensive drugs. Before the 2022 law, Medicare was prohibited from negotiating with pharmaceutical firms to secure more favorable drug prices for participants in the government health program. 

    Under the new agreement, lower prices for the 15 drugs will take effect in 2027 for medications bought through Medicare’s Part D prescription plan, CMS said. The discounts will range from 38% to 85% off the medications’ list prices, according to the agency. 

    The best-known drugs covered by the agreement include Novo Nordisk’s Ozempic and Wegovy, popular medications used for diabetes treatment and weight loss, while other drugs on the list are used to treat common diseases such as asthma and prostate cancer. 

    The cost of prescription drugs ranks among the top concerns of seniors, according to AARP. 

    Starting in 2025, the Inflation Reduction Act also introduced a $2,000 out-of-pocket spending cap for seniors. Because that spending limit is adjusted annually for inflation, it could reach about $2,200 in 2027 based on current trends. Medicare enrollees pay nothing for covered prescriptions above that amount. In other words, the negotiated prices for the 15 drugs could help seniors lower their costs until they hit that threshold.

    About 5.3 million people with Medicare Part D coverage used the 15 drugs to treat diseases such as diabetes and asthma, CMS said. The medications account for $40.7 billion in spending in Medicare Part D.

    Aside from savings that individuals might see on their prescriptions, the lower drug pricing will benefit Medicare itself, Merith Basey, executive director of Patients For Affordable Drugs, an advocacy group for lowering prescription costs, told CBS News. 

    “Medicare is using its bargaining power to lower prices on the most expensive drugs covered by the program,” Basey said. “The savings gained from the new, lower negotiated prices are what allow the program to pay for the out-of-pocket cap.”

    The program’s ability to negotiate drug costs also represents “the most powerful tool we currently have in place to rein in drug prices and hold the pharmaceutical industry accountable,” she added.

    Medicare’s negotiations are separate from deals negotiated by President Trump to lower prices for Zepbound, Ozempic and Wegovy, announced earlier this month. Under that agreement — which covers eligible patients on Medicare, Medicaid and the planned TrumpRX pharmaceutical website — the monthly cost of the GLP-1 drugs will range from $245 to $350, down from as high as $1,350 per month.

    However, the price for Medicare enrollees for Wegovy and Ozempic under the earlier deal will be $245, less than the $274 negotiated by CMS. In Monday’s announcement, CMS didn’t specify how the two programs might work together, and the agency didn’t immediately respond to a request for comment.

    Edited by

    Alain Sherter

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  • Trump Administration Says Lower Prices for 15 Medicare Drugs Will Save Taxpayers Billions

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    NEW YORK (AP) — Pharmaceutical companies have agreed to slash the Medicare prices for 15 prescription drugs after months of negotiations, reductions that are expected to produce billions in savings for taxpayers and older adults, the Trump administration said.

    But the net prices it unveiled for a 30-day supply of each drug are not what Medicare recipients will pay at their pharmacy counters, since those final amounts will depend on each individual’s plan and how much they spend on prescriptions in a given year.

    Health Secretary Robert F. Kennedy Jr. touted the deals as part of the administration’s efforts to address affordability concerns among Americans. The Medicare drug negotiation program that made them possible is mandated by law and began under President Joe Biden’s administration.

    “President Trump directed us to stop at nothing to lower health care costs for the American people,” Kennedy said in a statement Tuesday evening. “As we work to Make America Healthy Again, we will use every tool at our disposal to deliver affordable health care to seniors.”

    The announcement marks the completion of a second round of negotiations under a 2022 law that allows Medicare to haggle over the price it pays on the most popular and expensive prescription drugs used by older Americans, bringing the total number of negotiated drug prices to 25. The new round of negotiated prices will go into effect in 2027. Reduced prices for the inaugural round of 10 drugs negotiated by the Biden administration last year will go into effect in January.


    Price negotiations apply to drugs treating diabetes, asthma, cancers and more

    The latest negotiated prices apply to some of the prescription medications on which Medicare spends the most money, including the massively popular GLP-1 weight-loss and diabetes drugs Ozempic, Rybelsus and Wegovy. Some of the other drugs involved in the negotiations include Trelegy Ellipta, which treats asthma; Otezla, a psoriatic arthritis drug; and various drugs that treat diabetes, irritable bowel syndrome and different forms of cancer.

    Dr. Mehmet Oz, Centers for Medicare and Medicaid Services administrator, said the administration delivered “substantially better outcomes for taxpayers and seniors in the Medicare Part D program” than the previous year’s deals.

    Under the first round of Medicare price negotiations, the Biden administration said the program would have saved about $6 billion on net covered prescription drug costs, or about 22%, if it had been in effect the previous year. The Trump administration said its latest round would have saved the government about $8.5 billion in net spending, or 36%, if it had been in effect last year.

    It’s unclear exactly how much money the newly announced deals could save Medicare beneficiaries when they are buying prescription drugs at the pharmacy because those costs are determined by various individual factors.

    A new rule that kicked off this year also caps out-of-pocket drug costs for Medicare beneficiaries at $2,000, giving some relief to older adults affected by high-cost prescriptions. The administration said estimated out-of-pocket savings for Medicare beneficiaries with drug plans is about $685 million.

    Spencer Perlman, director of health care research at Veda Partners, said the Trump administration’s improved outcomes probably resulted from the mix of drugs being negotiated and lessons learned from the first year of negotiations.

    Net drug prices are proprietary, he said, but “if we take the administration at their word, I think it demonstrates that they have secured meaningful price concessions for seniors, meaning the Medicare Drug Price Negotiation Program is working as intended.”


    Medicare recipients can’t get GLP-1 drugs for obesity, but the administration is making changes

    The GLP-1 weight-loss drugs that were part of the negotiations have been especially scrutinized for their high out-of-pocket costs. Yet it’s still unclear to what extent Medicare beneficiaries who want to use the drugs to treat obesity will be able to do so.

    Medicare has long been prohibited from paying for weight-loss treatments, but a separate deal recently announced between the Trump administration and two pharmaceutical companies included plans for a pilot program that will expand coverage for the drugs to additional high-risk obese and overweight people.

    The Trump administration this year has also negotiated several unrelated deals with drug companies to lower the cost of their products for the wider population.

    Pharmaceutical companies, meanwhile, have sued over the Medicare drug negotiations enabled by the 2022 Inflation Reduction Act and remain opposed to them.

    “Whether it is the IRA or MFN, government price setting for medicines is the wrong policy for America,” Alex Schriver, senior vice president of public affairs at the Pharmaceutical Research and Manufacturers of America, or PhRMA, said in a statement. “These flawed policies also threaten future medical innovation by siphoning $300 billion from biopharmaceutical research, undermining the American economy and our ability to compete globally.”

    Next year, Medicare will negotiate prices for another round of 15 drugs, including physician-administered drugs for the first time.

    Copyright 2025 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

    Photos You Should See – Nov. 2025

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  • How rising Medicare premiums could impact what your 2026 Social Security check

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    A higher Medicare premium set to go into effect in 2026 will push the monthly charge above $200 for the first time, with the increase likely to erode next year’s cost-of-living increase for millions of Social Security recipients.

    The premium for Medicare’s Part B, which covers doctor visits and other outpatient services, will rise 9.7% to $202.90, an increase of $17.90 from the current $185 monthly cost, the Centers for Medicare & Medicaid Services said earlier this month. It’s the largest increase since 2022, when the Part B premium jumped 15%.

    The Part B deductible — the amount seniors must pay out of pocket before their coverage kicks in— is also rising about 10%, jumping to $283 next year from this year’s $257. 

    The Part B premium, which is deducted automatically from seniors’ monthly Social Security checks, is rising at a rate that’s three times that of inflation, partly due to a rise in underlying health care costs, Anne Montgomery, senior health policy expert at the National Committee to Preserve Social Security and Medicare (NCPSSM), said in a blog post. The Medicare premium increase means that seniors may not have much room to keep up with inflation, Max Richtman, the president and CEO of the same group, told CBS News.

    “So many rely on [Social Security] for all or most of their income,” he said. “This is gonna hurt.”

    The Social Security Administration set next year’s cost-of-living increase at 2.8%, which will boost the average Social Security paycheck by $56 to about $2,071 per month.

    The Medicare Part B premium hike will consume about a third of next year’s COLA, effectively lowering the rate to 1.9% — far below the current inflation rate of 3%, according to NCPSSM’s analysis. People with lower monthly benefits could even see an effective COLA of zero, the group said.

    Rising health care costs

    Health care costs have been rising for all Americans, contributing to the sticker shock that seniors and other groups are experiencing. In 2023, Americans spent an average of $1,514 on out-of-pocket health care costs, an increase of 9% from 2020 on an inflation-adjusted basis, according to KFF.

    Aside from underlying health care inflation, Medicare’s costs are also increasing because of increased demand for medical services, CMS said this month.

    Working adults will also face higher health care premiums in 2026. Roughly 22 million Americans who get their health insurance through the Affordable Care Act (ACA) marketplaces will also be faced with steep rate hikes if Congress fails to extend premium tax credits, which help lower the cost for the majority of people on ACA plans. 

    Those credits are set to expire at the end of 2025, which became the main sticking point in the recent government shutdown. Without an extension, Americans who rely on the tax credit could see their costs more than double in 2026, KFF estimates. 

    Workers with employee-sponsored coverage are also likely to see their costs climb next year, with most expected to pay 6% to 7% more for their 2026 plans, according to an analysis from consultant Mercer.

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    Aimee Picchi

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  • Senior citizens will pay a lot more for Medicare in 2026

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    (CNN) — Senior citizens are the latest group of Americans to face steep increases in their health insurance premiums for 2026.

    Medicare Part B premiums will jump nearly 10% next year, the largest increase in four years and second-largest hike, in dollar terms, in the program’s history. The standard monthly premium will be $202.90, an increase of $17.90 from this year, according to the Centers for Medicare and Medicaid Services. That will eat up nearly one-third of the $56 monthly Social Security cost-of-living adjustment that retirees will receive in 2026.

    The steep increase in premiums for Medicare Part B — which covers doctors’ visits, outpatient hospital services, medical equipment and drugs administered by physicians, among other services — comes at a time when health insurance premiums are rising sharply for those with job-based coverage and Affordable Care Act policies. This upward trend puts more pressure on Americans already struggling with affordability as the prices of food, utilities and other necessities remain stubbornly high.

    “In a world in which people are concerned about the affordability of health care and all other needs, it’s pretty distressing that this increase is so large,” said Jeanne Lambrew, director of health care reform at The Century Foundation.

    Increasing medical and pharmaceutical costs, as well as usage, are common drivers of the rise in health care premiums across coverage types.

    Medicare is also contending with the continuing wave of baby boomers becoming eligible to enroll, plus the ongoing shift toward surgeries and other medical services being performed at outpatient facilities, rather than in hospitals, where care is covered by Medicare Part A, said Rachel Schmidt, research professor at Georgetown University’s Medicare Policy Initiative.

    CMS noted that monthly premiums would have risen by another $11 had it not approved a change in payment for skin substitutes that the agency says will reduce spending by nearly 90% on the wound care products. Medicare shelled out more than $10 billion for these products last year, up from $256 million in 2019.

    Meanwhile, Medicare Part D prescription drug policies, which are offered by insurers, will see fewer changes for 2026 than they did for this year. The Biden administration had to rush last fall to stand up a multibillion-dollar subsidy program for insurers to prevent steep premium increases stemming from the Inflation Reduction Act. The law, which the Democrat-led Congress approved in 2022, required insurers to be on the hook for more of the drug costs once enrollees hit the catastrophic coverage phase above a $2,000 cap.

    The number of plans being offered for 2026 will decrease modestly, according to consulting firm Oliver Wyman, which noted that Elevance is exiting the market. Many insurers are hiking their premiums by as much as $50 for next year, though some are lowering them or holding them steady.

    “If seniors in the standalone PDP market are willing to shop, there is still stability,” said Brooks Conway, a principal at Oliver Wyman.

    Roughly 69 million Americans are enrolled in Medicare, which also covers people with disabilities. The annual open enrollment period ends December 7.

    Medicare Advantage market retrenches

    Medicare Advantage, which covers just over half of Medicare beneficiaries, is going through a second year of major changes. The overhaul is being spurred by medical costs outpacing reimbursements from the federal government, which pays insurers to offer coverage to Medicare enrollees.

    Many enrollees will have to search for new coverage for 2026 since the number of offerings is tumbling 10% to 3,373 plans, according to Oliver Wyman. Major insurers, including CVS Aetna, Elevance, Humana and UnitedHealthcare, are reducing their plan options in at least 100 counties. The changes are expected to affect just over 2 million people.

    (These figures do not include special needs plans that cater to enrollees with chronic conditions or those who are dually eligible for Medicaid. These plans will have more offerings for 2026 than they did this year.)

    In certain counties, there will be fewer policies offered with $0 premiums and fewer PPO plans, which have wider provider networks, said Greg Berger, a partner at Oliver Wyman. Insurers are primarily seeking to exit or scale back their less profitable products and geographic areas.

    “A lot of MAPD plans are trying not to grow,” Berger said, referring to Medicare Advantage plans with prescription drug coverage.

    And for the first time, some Americans will have no Medicare Advantage plans to choose from. Blue Cross and Blue Shield of Vermont and UnitedHealthcare decided to discontinue their coverage in the Green Mountain State, leaving traditional Medicare as the only option for residents in eight counties.

    Yet even with the pullbacks, most Medicare beneficiaries will have an array of options in 2026 — 39 plans, on average, down from 42 plans this year.

    “Millions of Medicare beneficiaries will continue to have access to a broad range of affordable coverage options in 2026,” Dr. Mehmet Oz, CMS’ administrator, said in a statement.

    Also, fewer plans will offer $0 deductibles for prescription drugs, while maximum out-of-pocket limits for medical care are rising $490, or about 10%, on average. Among Medicare Advantage plans with drug coverage that have a monthly premium, the average premium will increase to $66 next year, up from $60 this year.

    What’s more, the supplemental benefits that Medicare Advantage offers enrollees, such as funds for over-the-counter medicines, dental care and vision services, are getting skimpier. The dental allowance, for instance, is declining 10% to $2,107, on average, Berger said.

    The current disruptions in the market, however, don’t mean that Medicare Advantage will continue to shrink. Over the longer term, the program is still an attractive market for insurers, Schmidt said.

    “It’s not going away any time soon,” she said.

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  • BBB issues warning about Denver company after complaints about billing fraud

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    The Better Business Bureau issued a warning that a Denver business might be defrauding Medicare and its customers.

    The BBB’s advisory, posted Oct. 27, reported that the organization received complaints from two people who said they received bills from Centennial Medical Supplies for products they never ordered or received.

    Since Sept. 15, 31 people left reviews on the BBB’s website alleging that Centennial Medical Supplies billed their insurance for products they never ordered. Those who specified the products said the company charged them and their insurance for catheter supplies they didn’t need or receive.

    The true number of fraudulent claims may be higher, since not everyone looks at their insurance statements carefully, particularly if Medicare and their secondary plan covered the full costs, said Cameron Nakashima, digital campaigns manager at the BBB.

    “Scammers are hedging their bets on people not checking their statements,” he said.

    Someone responding to Centennial Medical Supplies’ email, who didn’t give a name, said they would look into any cases of improper billing if they received the patients’ information. The BBB previously reported that the company didn’t respond to its attempts to resolve customer complaints.

    “Thank you for bringing this to our attention. There appears to have been a mistake,” the email said.

    Two people were working at an office listed as the company’s address in south Denver. The one who answered the door said she was hired to “manage the mail” and didn’t know anything about Centennial Medical Supplies’ operations. The office had only one desk, and nothing suggested that other people typically worked there.

    The BBB’s research suggests a previous owner was less than diligent when deciding who to sell his medical supply company to, Nakashima said.

    “It was a legitimate business at one point, as far as we can tell,” he said.

    Billing for medical equipment has become a significant source of income for scammers. Generally, people committing fraud obtain legitimate beneficiaries’ Medicare numbers and other insurance information, and use that to file what look like real claims for catheters or other items. Insurance generally covers the claims, with the person whose information was stolen finding out only if they receive a bill.

    In June, the federal government announced charges against 324 people allegedly responsible for $14.6 billion in fraudulent charges to Medicare for catheters and other medical equipment.

    Billing to Medicare for urinary catheters increased tenfold from the start of 2022 to the end of 2023, with seven companies that had recently changed hands driving most of the increase, according to The Washington Post. A trade group representing insurers estimated Medicare may have wrongfully paid out about $2.8 billion over two years.

    Federal investigators also announced arrests in similar scams involving back and knee braces in 2019 and COVID-19 tests in 2023.

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    Meg Wingerter

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  • Minnesota commerce commish, MnSure CEO say insurance premium spikes at heart of government shutdown

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    Hundreds of thousands of Minnesotans are facing sticker shock as the enrollment period for health insurance on the state marketplace opened Nov 1.

    The increase is in large part due to the expiration of the Affordable Care Act — or “Obamacare” — tax credits, as well as changes in Medicaid reimbursement under President Trump’s “Big Beautiful Bill.”

    The battle over tax credits and Medicaid reimbursements is at the heart of the federal government shutdown. Democrats have refused to vote yes on re-opening the government until credits and payments are restored.

    Republicans say they want to negotiate the health insurance subsidies separately, and only pass what they call a “clean resolution.”

    The premium increases are staggering for Minnesotans, and affect those who are purchasing their health insurance on the state-backed MnSure website.

    There are 187,000 Minnesotans who buy individual policies through MnSure, and the average increase is 22%. Another 202,000 Minnesotans covered by small group plans through MnSure will see an average increase of 14%. 

    State Commerce Commissioner Grace Arnold, who oversees insurance rates, and MnSure CEO Libby Caulum spoke with WCCO’s Esme Murphy on WCCO Sunday Morning at 10:30 a.m. Both blame the federal government showdown for the increases.

    “The expectation for insurers is that fewer people will have coverage,” Arnold said. “The people who tend to stay in coverage are sicker.”

    There is a big difference in companies’ increases. On the individual market, Medica has the biggest increase at 30%, while Quartz Health Plan is the smallest at 7%.

    “You can come to our website, MnSure.org, look at all those options. You can switch plans if you find a better deal for you and your family,” Caulum said.

    The enrollment period is from Nov. 1, 2025, to Jan. 15, 2026. If you want benefits starting Jan. 1, 2026, you need to enroll by Dec. 15, 2025. Otherwise, your coverage will start on Feb. 1, 2026.

    You can watch WCCO Sunday Morning with Esme Murphy and Adam Del Rosso every Sunday at 6 a.m. and 10:30 a.m.

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  • Most Americans fear rising health care costs, poll finds | Long Island Business News

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    Most U.S. adults are worried about care becoming more expensive, according to a new , as they make decisions about next year’s health coverage and a keeps future health costs in limbo for millions.

    About 6 in 10 Americans are “extremely” or “very” concerned about their health costs going up in the next year, the survey from The Associated Press-NORC Center for Public Affairs Research finds — a worry that extends across age groups and includes people with and without .

    Many Americans have other health care anxieties, too. The poll found that about 4 in 10 Americans are “extremely” or “very” concerned about not being able to pay for health care or medications they need, not being able to access health care when they need it, or losing or not having health insurance.

    beneficiaries are already shopping for next year’s coverage, and open enrollment periods for many other health plans are approaching quickly in November. Federal policies have left millions of people at risk of skyrocketing health insurance premiums or of losing their health insurance altogether. The findings show that many Americans are feeling vulnerable to spiking , with some expressing concerns about whether they’ll have coverage at all.

    Latoya Wilson, an independent nurse consultant in Lafayette, Louisiana, currently uses a health insurance plan from the marketplace. But in the past two weeks, the 46-year-old has applied for more jobs than she had previously in her life, largely because she’s concerned about her premiums going up and wants the stability of employer-sponsored insurance.

    “Even before these health care cuts came into play, I was already having a significant issue getting the care that I needed this year,” she said. “Anything worse than what I already have is pretty scary.”
    Health care remains important to Americans when it’s center stage in Washington

    About 8 in 10 U.S. adults say the issue of health care is “extremely” or “very” important to them personally. That includes about 9 in 10 Democrats and three-quarters of Republicans, and it puts health care next to the economy among Americans’ top issue priorities.

    That significant attention on the issue raises the political stakes in what’s already been a crucial moment for federal health policy in the nation’s capital.

    President Donald Trump’s mega-bill passed this summer cuts more than $1 trillion from federal health care and food assistance over a decade, largely by imposing work requirements on those receiving aid and by shifting certain federal costs onto the states. Republicans say the cuts will prevent people who don’t need aid from gaming the system, but the cuts will ultimately result in millions of people losing health insurance coverage, according to projections from the nonpartisan Congressional Budget Office.

    More urgently, a congressional deadlock over Affordable Care Act subsidies that expire this year has thrown the federal government into a shutdown that’s dragged into a fourth straight week with no end in sight. Democratic lawmakers want any funding bill they sign to extend the subsidies, which have made ACA premiums less expensive for millions of people. Republicans in Congress have expressed willingness to negotiate on the issue, but only after the government is reopened.

    In interviews, some Americans said they doubted government leaders would take the necessary action to address their concerns on health care.

    “It is the federal government’s job to provide a better way of life for its people,” said Caleb Richter, a 30-year-old certified nursing assistant in Belleville, Wisconsin, who identifies as an independent. ”Right now, it just feels like they’re not trying.”

    But the poll reveals a deep ideological divide over what the government’s role should be, with Democrats far more likely than Republicans to say it’s the federal government’s job to make sure all Americans have health coverage. About 8 in 10 Democrats say this, compared with about one-third of Republicans.
    Most US adults disapprove of Trump’s handling of health care, the poll finds

    Health care continues to be a weakness for Trump. Only about 3 in 10 U.S. adults approve of the Republican president’s handling of health care, which hasn’t changed meaningfully since September. Almost all Democrats disapprove of his approach, but so do about 8 in 10 independents and about one-third of Republicans.

    Wilson, a Democrat, said she thinks Trump should be “doing things that affect the good of the group” when it comes to health care, including catering more to working-class Americans.

    But Michelle Truszkowski, a disabled veteran in Sterling Heights, Michigan, who is politically conservative, said she appreciates how Trump is focused on cutting and abuse in the health care system.

    “I like that people who shouldn’t be getting benefits from the government are getting kicked off of them,” the 48-year-old said. “Health care is not a right. It’s a privilege.”
    Democrats trusted more than Republicans on health care, but many trust neither

    About 4 in 10 U.S. adults say they trust the Democrats to do a better job handling health care, compared with about one-quarter who trust the Republicans more. About one-quarter trust neither party, and about 1 in 10 trust both equally.

    Americans are more likely to trust their own party on health care, generally speaking, but 76% of Democrats trust their party more on health care, while only 57% of Republicans have more trust in theirs.

    Independents are especially likely to trust neither party on health care — about half of independents say this. But the remaining independents are more likely to trust the Democrats.

    Richter, in Wisconsin, said he wishes Congress would put more faith and funding into hospital staffers who know how to help patients. He said he’d be fine with paying higher taxes if it meant ensuring health care for people who need it.

    But instead of working toward solutions, he said, federal lawmakers are acting “like a bunch of high school arguing.”

    “My faith that something will get done is very, very low at this point,” Richter said. “It just feels like they don’t really care.”


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  • Private Medicare, Medicaid plans exaggerate in-network mental health options, watchdogs say

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    Companies running private Medicare and Medicaid insurance plans inaccurately list many mental health professionals as being available to treat the plans’ members, a new federal watchdog report says.

    The investigators allege that some insurers effectively set up “ghost networks” of psychologists, psychiatrists, and other mental health professionals who purportedly have agreed to treat patients covered by the publicly financed Medicare and Medicaid plans. In fact, many of those professionals do not have contracts with the plans, do not work at the locations listed, or are retired, the investigators said.

    The Office of Inspector General for the Department of Health and Human Services, which oversees the giant Medicare and Medicaid health programs, released its findings in a recent report.

    The report focuses on insurers the government pays to cover people in Medicare Advantage plans and in privately managed Medicaid plans. About 30% of all Americans are covered by such insurance, the report says. The government pays the insurers hundreds of billions of dollars annually. 

    The companies are paid set rates per person they cover and are allowed to keep whatever money they don’t spend on patient care. The insurers are required to have adequate numbers of health care professionals under contract to serve patients in each region they cover.

    But the new report found that 55% of mental health professionals listed as in-network by Medicare Advantage plans were not providing such care to any of the plans’ members. The figure was 28% for Medicaid managed care plans.

    Some mental health professionals told investigators they shouldn’t have been listed as in-network care providers for the insurers’ members, because they no longer worked at the locations listed or because they didn’t participate in the Medicare Advantage or Medicaid managed care plans. Others said they were working as administrators and no longer providing patient care.

    In one case, the report says, a private Medicaid plan listed a mental health professional as providing care in 19 practice locations. But when the investigators checked, a receptionist at one of the clinics said the person had retired a few years ago.

    Jeanine Simpkins of Mesa, Arizona, learned how skimpy the networks can be when a 40-year-old family member was in crisis this fall. Simpkins struggled to find a drug rehabilitation program that would accept the Medicare Advantage insurance the relative is on because of a disability.

    Simpkins said she contacted about 20 rehab programs, none of which would take the Medicare insurance plan. “You feel kind of dropped,” she said. “I was pretty surprised, because I thought we had something good in place for her.”

    Simpkins’ relative eventually enrolled in part-time hospital care instead of an inpatient rehabilitation center.

    It can be challenging for patients to find timely, nearby care, for all kinds of health problems, from colds to cancer. 

    But Jodi Nudelman, a regional inspector general who helped write the federal report, said in an interview that the stakes can be especially high for patients seeking mental health care. 

    “They can be particularly vulnerable,” she said. It can be daunting for people to acknowledge they need such care, and any roadblock can discourage them from trying to find help, she said.

    She added that taxpayers aren’t getting their money’s worth if insurers fail to meet obligations to provide sufficient care options for Medicare and Medicaid participants in the plans.

    The federal report focused on a sample of 10 counties in five states: Arizona, Iowa, Ohio, Oregon, and Tennessee. It included urban and rural areas. It did not identify the insurers whose networks were checked. 

    Susan Reilly, vice president of communications for the Better Medicare Alliance, a trade group representing Medicare Advantage plans, said managed care companies support federal efforts to improve access to mental health services. “While this report looks at a small sample of plans, we agree there’s more work to do and are committed to continuing that progress together with policymakers,” she said in a statement.

    The report’s authors said their sample was a good representation of the national situation. It looked at 40 Medicare Advantage plans and 20 Medicaid managed care plans.

    The report recommends government administrators make more use of medical billing data to confirm whether health professionals listed as in-network are providing care to patients covered by private Medicare and Medicaid insurance plans.

    The watchdogs also recommend that federal regulators create a national, searchable directory of mental health providers, listing which Medicare and Medicaid insurance plans each one accepts. Such a directory would help patients find care and would make it easier to double-check the accuracy of plans’ listings of in-network providers, they said.

    Federal administrators overseeing Medicare and Medicaid have taken steps toward creating such a directory, the authors said. Reilly, the industry representative, said managed care companies support the effort.

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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  • Health care at the heart of Capitol Hill standoff as shutdown looms – WTOP News

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    With a government shutdown just hours away, one of the sticking points between Republicans and Democrats involves health care, specifically whether to extend premium subsidies under the Affordable Care Act.

    With a government shutdown just hours away, one of the key sticking points between Republicans and Democrats involves health care, specifically whether to extend premium subsidies under the Affordable Care Act.

    The debate centers on enhanced tax credits that help millions of Americans afford insurance through ACA marketplaces. These subsidies are currently scheduled to expire at the end of 2025, but Democrats are pushing for action now to avoid disruptions during the upcoming open enrollment period.

    “Twenty-two million people across the country get their coverage through the Affordable Care Act marketplaces,” said Anne Reid, policy director of the Funders Forum on Accountable Health at the Milken Institute School of Public Health at George Washington University.

    “The vast majority of those folks have some level of subsidization of their coverage, which is tied to their income.”

    Reid warns that without an extension, millions could lose coverage or face unaffordable premiums.

    The credits were expanded in recent years to raise income thresholds, allowing more Americans to qualify for help.

    “The credits were enhanced in the sense that a higher minimum income was set so more people could qualify to receive some relief toward these premiums,” Reid said.

    Reid previously served as a senior congressional staffer, where she contributed to health workforce policy during the development of the Affordable Care Act.

    Democrats want the extension included in the continuing resolution needed to keep the government open. Reid said they view it as a must-pass provision.

    “Democrats are arguing that we need to handle this in must-pass legislation, which at the moment is the appropriations bill.”

    They also want to reverse earlier Medicaid cuts that could result in more than 10 million people losing coverage.

    But Republicans argue the funding bill should be a “clean” continuing resolution, focused solely on keeping the government running.

    “Let’s just keep the government going on current fiscal year levels through the middle of November, to give us some time to work things out and negotiate a longer-term package,” Reid said, summarizing the GOP position.

    University of Maryland finance professor David Kass said Democrats are pushing to extend the expanded benefits into 2026, but Republicans want to debate the issue separately from the stopgap funding measure.

    “Fewer Americans would be able to purchase health insurance” if the premium help isn’t available as open enrollment begins, Kass said.

    Reid said the timing is critical, not just for consumers, but for insurers who need clarity to set rates.

    “Days and weeks matter in terms of being able to rightsize the premium levels.”

    The potential shutdown could also hit the D.C. region particularly hard, given its large federal workforce.

    “Job security and financial security would very acutely be felt in the D.C. region, given our demographics and who all comprises the federal workforce,” Reid said.

    With open enrollment approaching and budget negotiations stalled, Reid said the lack of clarity could leave consumers in limbo and millions of Americans at risk of losing affordable health coverage.

    Get breaking news and daily headlines delivered to your email inbox by signing up here.

    © 2025 WTOP. All Rights Reserved. This website is not intended for users located within the European Economic Area.

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    Mike Murillo

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  • One-third of Gov. Jared Polis’ budget cuts involve Medicaid

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    Almost one-third of the budget cuts and sweeps of unused money that Gov. Jared Polis used to close a $249 million budget hole will come from Medicaid, and providers are trying to figure out how much disruption that will cause for them and their patients.

    H.R. 1, known as the “Big Beautiful Bill,” blew a roughly $783 million hole in the state budget in July, because Colorado’s tax laws automatically adjust to stay in harmony with the federal government’s. The legislature opted to undo some of those changes during a special session in August and gave Polis the authority to fill the rest of the gap.

    About $79.2 million of the $252 million in cuts came from the Colorado Department of Health Care Policy and Financing, which runs Medicaid in the state. The list includes a mix of reductions in the rates paid to people who provide care, unused funds swept from specific programs and plans to review some care types more strictly before paying.

    The largest cut, worth roughly $38.3 million, would roll back most of a 1.6% increase that most providers expected to get this year. Since providers received slightly higher rates in the first months of the fiscal year, it will work out to about a 0.4% increase, which is in line with recent years, the department said.

    Denver Health estimated the rollback would cost the city’s safety-net hospital about $5 million. The health system isn’t planning any layoffs or service reductions, but could cut back on nonessential maintenance and technology updates, CEO Donna Lynne said. As it was, the increase only partially offset growth in costs in recent years, she said.

    “We were already trying to absorb the difference between medical inflation and the 1.6%,” she said. The American Hospital Association estimated hospital costs rose about 5.1% in 2024.

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    Meg Wingerter

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  • Trump administration to close Miami organ donation group it calls ‘failing’

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    WASHINGTON — The Trump administration moved Thursday to shut down a Miami organ donation group, calling it “failing” because of underperformance, unsafe practices and paperwork errors.

    The Life Alliance Organ Recovery Agency is one of 55 organ procurement organizations, or OPOs, nonprofit agencies around the country that coordinate the recovery of organs from deceased donors and help match them to patients on the nation’s transplant waiting list.

    The administration cited an investigation that found a 2024 case where an unspecified mistake led a surgeon to decline a donated heart for a patient awaiting surgery.

    In a news briefing, Dr. Mehmet Oz, who heads the Centers for Medicare and Medicaid Services, said problems included would-be donations that went unrecovered, sending some donated organs to the wrong place and a lack of staff.

    Life Alliance, a division of the University of Miami Health System, can appeal the decision. If it is shut down, it would mark the first time the federal government has decertified an OPO.

    Life Alliance didn’t immediately respond to a request for comment.

    More than 100,000 Americans are on the transplant list and thousands die waiting because there aren’t enough donations to go around. Last year there were more than 48,000 transplants, a record, the vast majority from deceased donors.

    Changes to the transplant system have been underway for years to increase donations, reduce waste of potentially usable organs and address other concerns. They include some new safeguards after complaints last year that a different OPO didn’t stop donation preparations quickly enough when some patients showed signs of life, prompting some people to opt out of donor registries. Organ donation can proceed only after a hospital has declared someone dead — and by law, OPOs cannot be involved in that decision.

    On Thursday, Oz sought to reassure would-be donors.

    “Congress has thoughtfully and aggressively pursued some horrifying stories that have chilled some Americans’ enthusiasm for donating organs. We are here today to tell you this system is safe. It’s rigorously being addressed,” he said, adding later, “I want to applaud the OPOs that are doing a great job because most are.”

    —-

    The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

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  • Coloradans can get updated COVID vaccines, but insurance might not cover the shots

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    Anyone 6 months and older who wants a COVID-19 shot in Colorado can now get one, but the vaccine will only be free for those with the right insurance — at least for now.

    Initially, pharmacies couldn’t administer the updated shots in Colorado unless a patient had a prescription. The state allows pharmacists to administer vaccines recommended by the Centers for Disease Control and Prevention’s advisory committee, but not other shots.

    Dr. Ned Calonge, chief medical officer for the state health department, responded by issuing a standing order — essentially, a prescription for every resident – allowing them to get vaccinated at retail pharmacies.

    But that order doesn’t guarantee insurance will cover the shots or that pharmacies will choose to stock them. Last year, fewer than half of people over 65 nationwide received an updated COVID-19 shot, with uptake dropping further in younger age groups, raising questions about whether health care providers will believe demand is high enough to justify buying the vaccine.

    “The standing order provides accessibility. It doesn’t necessarily provide availability,” Calonge said Tuesday.

    The Colorado Division of Insurance issued a draft rule last week that would require state-regulated plans to cover COVID-19 vaccines without out-of-pocket costs for people of any age, assuming the division passes it as written. Insurance cards from state-regulated plans typically have CO-DOI printed in the lower left corner.

    The state’s rule doesn’t apply to federally regulated plans, which account for about 30% of employer-sponsored insurance plans in Colorado, Calonge said. Typically, however, those plans try to offer competitive benefits, since they mostly serve large employers, he said.

    “My hope would be they would want to keep up with other insurers,” he said.

    This isn’t the first time that people on state-regulated plans have had benefits not guaranteed for people with federally regulated insurance.

    Colorado capped the cost of insulin and epinephrine shots to treat severe allergic reactions in state plans, but couldn’t require the same for plans the state doesn’t oversee. In those cases, it offered an “affordability program” requiring manufacturers to supply the medication at a lower cost for people who aren’t covered by the state caps, Medicare or Medicaid.

    At least two Colorado insurers surveyed by The Denver Post said all of their plans will cover COVID-19 vaccines, while others hedged.

    Select Health, which sells Medicare and individual marketplace plans in Colorado, said its plans currently cover COVID-19 vaccines without out-of-pocket costs for everyone. Kaiser Permanente Colorado said in a message to members that it will pay for the shot for anyone 6 months or older.

    Donna Lynne, CEO of Denver Health, said the health system’s insurance arm is waiting on clarification about when it should cover the vaccines. Denver Health Medical Plan offers multiple plan types, some state-regulated and some under federal rules, she said.

    “It’s less of a decision on our part than understanding what the health department and the insurance department are saying,” she said. “You can’t have one insurance company saying they are doing it and one saying they aren’t doing it.”

    Anthem said it considers immunizations “medically necessary” if the American Academy of Pediatrics, American Academy of Family Physicians or the CDC’s vaccine advisory committee has recommended them, but didn’t specify whether it would charge out-of-pocket costs for medically necessary vaccines.

    If those bodies stated that certain people could get a particular vaccine — but not that they should — Anthem would decide about coverage “on an individual basis,” its website said. The other groups have recommended the shots for people over 18 or under 2, with the option for healthy children in between to get a booster if their parents wish.

    The state’s Medicaid program is still waiting for guidance from federal authorities about whose vaccines it can cover, according to the Colorado Department of Health Care Policy and Financing, and Medicare isn’t yet paying for the shots.

    For most of the COVID-19 vaccines’ relatively brief existence, they were free and recommended for everyone 6 months and older. In 2024, the federal government stopped paying for them, which meant uninsured people no longer could be sure they could get the shot without paying.

    Almost all insurance plans still were required to pay for the shots, though, because the CDC’s Advisory Committee on Immunization Practices recommended them.

    In previous years, the committee recommended updated shots within days of the U.S. Food and Drug Administration approving them. In late August, the FDA approved the updated vaccines for people over 65 and those with one of about 30 conditions increasing their risk of severe disease, including asthma, obesity and diabetes.

    Doctors still could prescribe the vaccine “off-label” to healthy people, in the same way that they prescribe adult medications for children when an alternative specifically approved for kids isn’t available.

    This year, however, the committee won’t meet until Thursday, and may not recommend the shots when it does. Secretary of Health and Human Services Robert F. Kennedy Jr. dismissed all of the committee’s members earlier this year and replaced them with new appointees, most of whom oppose COVID-19 vaccines.

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    Meg Wingerter

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  • Trump’s New Plan for Medicare: Let AI Decide Whether You Should Be Covered or Not

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    Donald Trump says he is Making America Great Again, which seems like it might be code for: making everything shittier, less affordable, and less efficient. Certainly, when it comes to the realm of public services, the White House seems to be doing everything in its power to make the century-old social welfare programs—like Social Security and Medicare—significantly less helpful.

    The latest unfortunate example of this unfurled itself this week with the announcement of a new pilot program being trialed by the Centers for Medicare and Medicaid Services. The pilot, which the New York Times reports is scheduled to begin next year in six different states, will use artificial intelligence software to determine whether certain kinds of coverage are “appropriate” or not. In a press release on the agency’s website that feels very DOGE-like, the CMS notes that its new program will “Target Wasteful, Inappropriate Services in Original Medicare.” It reads: 

    The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care.

    Yes, you wouldn’t want to have unnecessary care, would you? That would be terrible. The press release continues:

    Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars.

    Prior authorization is the process whereby medical providers are required to check with insurance companies before providing certain types of care. Traditionally, folks enjoying public benefits with Original Medicare do not need to worry about this sort of thing, but for those using the more “modernized” program, Medicare Advantage, they seem to be getting hit with it all the time. In this case, recipients who are receiving Original Medicare will still be subjected to prior authorization through the pilot program. The AI algorithms will be used to determine whether the care recipients are getting represents an “appropriate” expenditure of “federal taxpayer dollars.” This is all packaged by the government as if it’s doing you some sort of favor. The press release states:

    The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for select items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use.

    The New York Times notes that algorithms of this sort have been subjected to litigation, while also noting that the AI companies involved “would have a strong financial incentive to deny claims,” and the new pilot has already been referred to as an “AI death panels” program. Gizmodo reached out to the government for information.

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    Lucas Ropek

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  • Healthcare IT Faces Disruption and Innovation Challenges as GOP Budget Cuts Loom: Insights From Black Book Weekly Survey

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    WASHINGTON, January 23, 2025 (Newswire.com)
    –
    Proposed federal healthcare budget cuts, aimed at achieving over $3 trillion in savings, are poised to create significant disruptions within the healthcare IT sector. Recent federal actions, including an executive order to withdraw from the World Health Organization (WHO) and the rollback of drug pricing reforms, have compounded challenges for healthcare providers and IT vendors. These findings are part of an in-depth Q1 2025 Black Book Research survey conducted with 110 IT leaders from provider health systems and physician organizations, 33 payer IT professionals, and 162 healthcare IT software and managed services vendors, including 108 firms specializing in Revenue Cycle Management (RCM). The survey sheds light on operational challenges, innovation opportunities, and strategic shifts required to adapt to these sweeping changes.

    Key Findings

    IT Overhauls Required for Medicaid and Medicare Changes: 91% of IT leaders reported that significant system reconfigurations are necessary to accommodate Medicaid’s transition to a per capita cap model and new reimbursement structures. Respondents highlighted challenges in updating IT systems for revised billing, eligibility tracking, and payment models driven by federal healthcare reforms.

    Rising Demand for Cost-Efficiency in RCM and Analytics: 83% of healthcare IT users indicated that maximizing reimbursements and managing financial risk would require a greater reliance on advanced RCM and analytics technologies. Proposed cuts to uncompensated care funding and site-neutral payments are accelerating demand for these cost-efficiency tools.

    Telehealth and Digital Health Growth at Risk: 68% of IT executives expressed concern that reduced financial incentives could hinder the expansion of telehealth and remote monitoring capabilities, especially in rural and underserved communities. Cuts targeting telehealth and facility fees are viewed as significant barriers to digital health growth.

    Compliance and Administrative Complexity: 88% of respondents emphasized the urgent need for integrated IT systems to manage compliance processes, including new Medicaid work requirements and eligibility tracking. Administrative burdens are expected to rise, creating demand for seamless IT integration.

    Cybersecurity as a Priority Amid Budget Constraints: The urgency of cybersecurity tools stems from the heightened risk of cyberattacks targeting healthcare systems, compounded by the sector’s increased reliance on IT to manage compliance and operational complexities. As federal budget cuts create financial constraints, nearly two-thirds of respondents prioritized scalable and cost-effective cybersecurity solutions to protect sensitive healthcare data. Vendors are focusing on deploying AI-driven threat detection systems, offering managed security services for resource-limited organizations, and ensuring compliance with HIPAA, GDPR, and other regulatory requirements. The emphasis on cybersecurity reflects its critical role in maintaining resilience and safeguarding patient trust during this period of uncertainty.

    Strategic Shifts for IT Vendors: 39% of vendor executives are focusing on cost-saving solutions, including cloud-based infrastructure, integrated RCM tools, and AI-powered analytics to meet evolving client needs.

    Federal Actions Compounding Healthcare IT Challenges

    On January 20, 2025, President Donald Trump signed an executive order initiating the United States’ withdrawal from the World Health Organization (WHO), potentially disrupting global health initiatives and data sharing critical to healthcare providers and IT vendors. Additionally, the administration has rescinded healthcare directives from the previous administration, including capping generic medication copayments at $2 and reducing payments for FDA-approved drugs, affecting cost structures for providers and patients.

    Doug Brown, Founder of Black Book Research, stated, “Healthcare providers and IT vendors are preparing for the wide-reaching implications of these budget cuts and policy changes. While cost reductions may provide short-term savings, they also pose significant risks to innovation, operational efficiency, and patient care. Vendors will play a crucial role in helping organizations navigate these challenges with adaptable, cost-effective solutions.”

    Opportunities for Resilience and Innovation

    The survey results highlight critical opportunities for healthcare IT vendors to:

    Support compliance with integrated solutions that simplify administrative processes: Integrated IT systems designed to streamline compliance management, such as tracking Medicaid work requirements, eligibility, and regulatory reporting, are in high demand. Vendors capable of delivering scalable solutions will be instrumental in reducing administrative burdens for healthcare providers adapting to new federal policies.

    Enhance financial efficiency through advanced RCM and analytics platforms: With seven in ten surveyed organizations identifying financial efficiency as a top priority, vendors specializing in Revenue Cycle Management (RCM) are positioned for growth. Key focus areas include:

    • Automating billing processes to accommodate new reimbursement models.

    • Providing predictive analytics tools that enable providers to optimize revenue streams and mitigate financial risks.

    • Delivering cost-efficient RCM solutions tailored for small and mid-sized practices, which are often disproportionately affected by budget cuts.

    RCM firms are actively investing in AI-driven tools that can adapt to dynamic billing requirements while enhancing payment accuracy.

    Prioritize cybersecurity to protect sensitive data amidst rising cyber threats: As the healthcare sector faces increasing cyberattacks, nearly two-thirds of respondents emphasized cybersecurity as a critical priority, despite financial constraints. Managed service vendors specializing in healthcare cybersecurity are developing scalable, cost-effective solutions to address these threats. Key cybersecurity measures include:

    • Deploying AI-driven threat detection systems to identify vulnerabilities in real-time.

    • Offering managed security services that cater to organizations with limited in-house IT resources.

    • Ensuring compliance with HIPAA, GDPR, and other regulatory requirements through comprehensive security frameworks.

    ____________________

    Healthcare technology and software companies with specific product focuses have significant opportunities to respond to the challenges and demands outlined in the press release. Below are the types of companies and examples of product categories they can address effectively:

    Revenue Cycle Management (RCM) Software Companies

    Opportunity: These companies can deliver advanced billing automation, predictive analytics, and cost-efficient tools to help providers optimize financial performance amidst budget cuts.

    • 2025 Top-Rated Vendors for RCM Software: Waystar, FInThrive, Experian Health, Veradigm, Optum, Conifer Health Solutions

    • 2025 Top-Rated Vendors for AI-Driven RCM Platforms: Change Healthcare, Waystar, R1RCM

    ____________________

    Cybersecurity and Managed Security Service Providers

    Opportunity: The growing threat of cyberattacks and regulatory complexities require companies offering scalable, AI-driven threat detection, and managed cybersecurity services to help healthcare organizations mitigate risks.

    • 2025 Top-Rated Vendors for Cybersecurity Platforms: Palo Alto Networks, CrowdStrike. ZScaler

    • 2025 Top-Rated Vendors for Cybersecurity Managed Services Providers: Clearwater, Fortified Health Security, Trustwave

    __________________

    Integrated IT and Compliance Solutions

    Opportunity: Vendors offering IT systems that integrate compliance tracking for Medicaid work requirements and regulatory reporting can alleviate administrative burdens.

    • 2025 Top-Rated Vendors for Integrated Compliance Platforms: ClearDATA, Kaseya, symplr, HealthStream

    ___________________

    Telehealth and Remote Monitoring Platforms

    Opportunity: Companies focusing on telehealth and remote monitoring solutions can address underserved communities’ needs and counteract challenges arising from reduced financial incentives.

    • 2025 Top-Rated Vendors for Telehealth Platforms: Amwell, Doximity, VSee Health

    • 2025 Top-Rated Vendors for Remote Monitoring: Andor Health, BioTelemetry (Philips), Vivify Health

    ________________

    Analytics and Data Platforms

    Opportunity: Advanced analytics tools that support financial efficiency, population health management, and operational insights are crucial for organizations adapting to new federal policies.

    • 2025 Top-Rated Vendors for Healthcare Analytics: Health Catalyst, Arcadia, MedeAnalytics

    • 2025 Top-Rated Vendors for Predictive Analytics for RCM: Optum360, IBM Watson, Inovalon

    ___________________

    Cloud Infrastructure and Interoperability Solutions

    Opportunity: Vendors specializing in cloud-based infrastructures and seamless interoperability solutions can support cost-saving measures and enable effective data exchange across systems.

    • 2025 Top-Rated Vendors for Cloud Providers: AWS, Microsoft Azure, Google Cloud.

    • 2025 Top-Rated Vendors for Interoperability Solutions: Infor, InterSystems, Redox.

    __________________

    Population Health and Value-Based Care Platforms

    Opportunity: Companies providing platforms for population health management and value-based care transitions can help providers meet new reimbursement model requirements.

    • 2025 Top-Rated Vendors for Population Health Solutions: Lumeris, Innovaccer

    • 2025 Top-Rated Vendors for Value-Based Care Platforms: Mahalo Health, CareAllies, Premier Inc, HealthEC

    • 2025 Top-Rated Advisory Firms for Value-Based Care Transitions: CareAllies, Premier Inc

    ____________________

    AI-Driven Clinical and Operational Tools

    Opportunity: AI-powered tools can streamline clinical workflows, optimize patient care, and reduce administrative burdens, aligning with providers’ cost-saving goals.

    • 2025 Top-Rated Vendors for Clinical Decision Support: IBM Watson Health, Nuance (Microsoft), Oracle Cerner, TruBridge

    • 2025 Top-Rated Vendors for Workflow Optimization: Qventus, MedEvolve, PerfectServe, LeanTaaS

    ___________________

    Digital Health and Patient Engagement Tools

    Opportunity: Companies offering patient engagement platforms and digital health tools can address gaps in care delivery and patient satisfaction as funding pressures rise.

    • 2025 Top-Rated Vendors for Engagement Tools: Intellichart, Salesforce Health Cloud, Kyruus

    • 2025 Top-Rated Vendors forPatient Portals: MyChart (Epic), AthenaCommunicator, Bridge Patient Portal

    ____________________

    Small and Mid-Sized Practice Solutions

    Opportunity: With small and mid-sized practices disproportionately affected, vendors providing tailored, affordable solutions can fill critical gaps.

    • 2025 Top-Rated Vendors for Practice Management and RCM: NextGen Healthcare, RXNT, Veradigm

    • 2025 Top-Rated Vendors for EHRs for Small Practices: ModMed, Practice Fusion.

    ___________________

    Strategic Reimbursement and RCM Advisory/Consulting Services

    Opportunity: The GOP healthcare budget cuts present opportunities for RCM consultants and reimbursement advisory firms to help providers navigate reimbursement changes, optimize revenue cycles, and mitigate financial risks while ensuring compliance with evolving regulations.

    • 2025 Top-Rated Consultants & Advisory Firms: Huron Consulting Partners, PwC, Kaufman Hall, Deloitte, Accenture

    _____________________

    About Black Book Research

    Black Book Research is an independent market research and public opinion company specializing in healthcare IT and vendor performance. With a focus on unbiased evaluations and actionable insights, Black Book empowers healthcare organizations with data-driven strategies to navigate a rapidly evolving landscape.

    Source: Black Book Research

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