ACA Rule Foreshadows New Plan Model in 2028
The Centers for Medicare & Medicaid Services finalized a rule that will reshape ACA marketplace offerings beginning in 2027‑2028. It introduces plans with 30% higher out‑of‑pocket costs and, for the first time, options without fixed provider networks, letting enrollees negotiate directly with doctors. The rule is projected to cost about $1.3 billion a year to implement and could cut enrollment by up to 2 million by 2027. Additionally, bronze and catastrophic plans see out‑of‑pocket maximums jump to $15,600 per individual and $31,200 per family.
Rep. Greg Landsman: [Had WISeR] Gone Through Congress, It Would Not Have Passed
In this episode of Healthcare Uncovered, Congressman Greg Landsman discusses CMS’s new WISER model, an AI‑driven prior‑authorization system being piloted in six states, including Ohio. He explains that the program uses artificial intelligence to deny Medicare claims, sparking confusion and...
The Five Revenue Streams That Run Through Every PBM Contract — and Five Needed Reforms
The article outlines the five primary revenue streams embedded in every Pharmacy Benefit Manager (PBM) contract—spread pricing, rebate retention, administrative fees, manufacturer‑direct payments, and owned‑pharmacy margin. While employers often see only the nominal administrative fee, the other streams are hidden...
The Blind Spot in Congress's Health Care Transparency Bill
The House Energy & Commerce Subcommittee will hold a hearing on a health‑care transparency package that mandates public reporting of ownership structures, mergers, debt and real‑estate details for hospitals, surgical centers and physician groups, with penalties up to $5 million for...
No One Likes Medicare Advantage | EP 4
In this episode of Healthcare Uncovered, hosts Joe Rotino and Wendell Potter expose how Medicare Advantage—private, for‑profit plans that replace traditional Medicare—cost taxpayers an extra $80‑$140 billion annually while imposing prior authorizations, narrow networks, denials, and up‑coding schemes on patients. Former...
Government Watchdog Agency Finds that Every High-Risk Acute Stroke Diagnosis Submitted by Medicare Advantage Insurers in Audit Was Upcoded
The HHS Office of Inspector General reported that Medicare Advantage insurers were likely overpaid by $462 million in 2021 due to unsupported acute‑stroke diagnoses used for risk adjustment. An audit of 97 enrollees found every acute‑stroke code lacked medical‑record evidence, indicating...
The $490,000 Denial
Pamela Talley, a 62‑year‑old retired physician, was air‑lifted to a Tucson trauma center after a severe bicycle crash in Arizona that left her wrist exposed and her elbow broken. Anthem Blue Cross and Blue Shield, part of Elevance Health, later...
After Eric Tennant’s Death, West Virginia Takes Aim at Prior Authorization
West Virginia enacted a law allowing beneficiaries of the state employee health plan to switch to an alternative medically appropriate treatment of equal or lesser cost without restarting the prior‑authorization process. The legislation was spurred by the death of coal‑mining...
Texas Republicans Invited Me to Testify About Big Insurance
A former health‑insurance executive testified before the Texas House Select Committee on Health Care Affordability, warning that insurer incentives reward cost‑cutting over patient benefit. He highlighted how narrow networks, claim denials, and prior authorizations boost margins while inflating premiums. The...
The Bill That Never Ends
Jeni Rae Peters, a single mother with employer‑provided insurance, accrued at least $30,000 in medical debt while treating stage‑2 breast cancer, illustrating how high‑deductible plans can bankrupt patients even when they are covered. A 2024 American Cancer Society survey found...
Five Ways to Start Fixing America’s Health Care System
The article outlines five legislative steps to begin fixing America’s health‑care system. It calls for breaking up vertically integrated insurers such as UnitedHealth, treating insurance medical directors as practicing physicians, and enforcing antitrust rules using the Herfindahl‑Hirschman Index. It also...
The Convenient Narrative Letting Insurers Off the Hook
Zack Cooper’s New York Times op‑ed attributes rising premiums chiefly to hospital market power, but industry insiders contend insurers also fuel costs. The piece explains how insurer consolidation gave payers bargaining leverage that spurred hospitals to merge, creating a costly arms race....
Health Care Costs Is the Issue Voters Can’t Afford to Ignore
Pope Leo XIV, the first American pontiff, declared universal health coverage a moral imperative at a Vatican‑WHO conference. A KFF follow‑up survey of 800 ACA marketplace enrollees found 80% paying higher premiums, 51% saying costs rose dramatically, and 9% dropping...
Cigna Reports Q1 Gains, Announces ACA Marketplace Exit
Cigna posted first‑quarter 2026 revenue of $68.5 billion, up 5%, and adjusted operating income of $2.1 billion, a 12% year‑over‑year gain that missed consensus EPS by five cents. The insurer lifted its full‑year adjusted income outlook to at least $30.35 per share....
WATCH NOW: Prior Authorization: Care, Delayed | EP 3
In this episode of Healthcare Uncovered, the hosts examine the burdens of prior authorization on patients and clinicians, featuring Dr. Wendy Dean, co‑founder of Moral Injury of Healthcare, and former health‑system executive Dr. Seth Glickman. They discuss how prior‑auth requirements...