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Medicare Advantage Plans Face Narrowing Margins as Health Costs Rise by 9.6%

Medicare Advantage Plans Face Narrowing Margins as Health Costs Rise by 9.6%

Medicare Advantage (MA) plans experienced a significant increase in health benefit costs, rising by a median of 9.6% in 2025. This surge in costs occurred while administrative expenses remained largely flat, leading to narrowing margins for these plans. The findings, from Sherlock Company's 2026 Medicare benchmark edition, are based on surveys of 11 Medicare-focused health plans covering 2.1 million MA and Special Needs Plan members. These plans collectively serve 15.4 million members, with Medicare products accounting for a median of 35% of their revenues. The report highlights that MA plans now cover over half of all eligible Medicare beneficiaries in the U.S. The administrative costs per member declined by 0.3% in 2025 on a constant-mix basis, marking the slowest rate of change since 2015. This reduction in the administrative cost ratio was primarily due to near double-digit premium growth, which expanded the denominator while administrative expenses stayed consistent. The health benefit ratio for conti...

Community Oncology Practices Face Financial Pressure from Policy Changes and Medicare Drug Price Negotiations

Community Oncology Practices Face Financial Pressure from Policy Changes and Medicare Drug Price Negotiations

Community oncology practices are experiencing significant financial pressure due to a confluence of policy changes, including drug price negotiation, Medicaid coverage adjustments, insurer utilization management, and 340B reform. According to oncology policy leaders at The American Journal of Managed Care’s annual Patient-Centered Oncology Care conference, reimbursement could decrease by 30% to 40% without legislative intervention. The Part D component of the Inflation Reduction Act (IRA) is already complicating planning, with Medicare-negotiated prices for several significant oral oncolytics, such as palbociclib (Ibrance), enzalutamide (Xtandi), pomalidomide (Pomalyst), and acalabrutinib (Calquence), set to take effect in 2027. These changes are forcing practices to adapt to new financial realities and operational challenges. Insurer utilization management, particularly prior authorization and step therapy, continues to burden practices, despite pledges for reform from the Department of Health and Human S...

Oregon Legislators Consider Nation's First Universal Healthcare System Proposal

Oregon Legislators Consider Nation's First Universal Healthcare System Proposal

Oregon is moving closer to potentially becoming the first U.S. state to implement a single-payer universal healthcare system. A panel, the Universal Health Plan Governance Board, established by the state legislature in 2023, is set to present its proposal for a universal health plan by December 1. This plan aims to provide medical, vision, dental, and mental health benefits for all state residents, from birth to death, without premiums, deductibles, or copayments, starting in 2032. Lawmakers could vote on the plan during the 2027 legislative session or refer it to voters as a ballot measure in 2028. The proposal seeks to maintain current healthcare spending levels by replacing insurance premiums and out-of-pocket costs with new corporate and personal taxes, combined with federal and state funding. Proponents argue that savings from reduced bureaucracy, fraud, and negotiated drug costs would allow for better benefits for more people. For example, a 30-year-old earning $55,000 currently paying $5,478 annuall...

Leonard Green Partners' Private Equity Practices Scrutinized in Safety-Net Hospital Destabilization

Leonard Green Partners' Private Equity Practices Scrutinized in Safety-Net Hospital Destabilization

Private equity firm Leonard Green & Partners (LGP) is under scrutiny for its role in the destabilization and eventual bankruptcy of Prospect, a multi-state hospital system. According to a report by the Center on Health Insurance Reforms (CHIR) at Georgetown University, LGP, as the controlling entity of Prospect, employed various asset-stripping and profit-maximization strategies. These practices, detailed in the report 'Hollowed Out: How Private Equity Destabilized Safety-Net Hospitals in Pennsylvania, Connecticut, and Rhode Island,' are cited as having disastrous results for the hospitals. The report highlights a broader issue within the healthcare system, where opaque financial relationships between insurers, providers, and middlemen contribute to higher prices, reduced competition, and increased administrative complexity. These issues are exacerbated by a web of cost-increasing incentives and conflicts of interest, ultimately harming consumers. The report suggests that many providers face no constraints...

Congresswoman Wilson Introduces Glaucoma Vision Act to Expand Screening Access and Research Funding

Congresswoman Wilson Introduces Glaucoma Vision Act to Expand Screening Access and Research Funding

Congresswoman Frederica S. Wilson (FL-24) has introduced the Glaucoma Vision Act of 2026, a legislative initiative aimed at broadening access to annual glaucoma screenings, delivering detection and treatment services to underserved communities, and investing in research to preserve and restore vision. According to a press release from Wilson's office, the bill seeks to mandate glaucoma screening coverage for eligible individuals with private insurance, Medicaid, and Federal Employees Health Benefits. It also proposes eliminating Medicare Part B cost-sharing for screenings for eligible people, with these coverage provisions generally set to take effect in 2027. The legislation targets high-risk populations, including adults aged 40 or older of African, Hispanic/Latino, or Asian ancestry, or those with clinical risk factors such as diabetes, a family history of glaucoma, elevated eye pressure, myopia, certain blood pressure conditions, or chronic corticosteroid use. Adults aged 60 or older would also qualify...

Congressman Jim McGovern Co-Sponsors Bipartisan Bill for Medically Tailored Meals Pilot Program

Congressman Jim McGovern Co-Sponsors Bipartisan Bill for Medically Tailored Meals Pilot Program

Congressman Jim McGovern has co-sponsored bipartisan legislation, H.R. 5439, known as the 'Medically Tailored Home-Delivered Meals Program Pilot Act.' This bill, co-sponsored with Congresswoman Nicole Malliotakis (NY-11), recently passed unanimously out of the House Ways and Means Committee, marking a significant step towards its final passage. The proposed legislation aims to establish a six-year Medicare pilot program. This program would involve 40 hospitals providing medically tailored meals to eligible Medicare beneficiaries who live at home and suffer from diet-impacted conditions, such as diabetes and heart failure, after their hospital discharge. The meals are designed by nutritionists to meet the specific health needs of each patient, and the program is intended to be budget-neutral, incurring no additional cost to taxpayers.

President Trump to Issue $500 ACA Refund Checks to Nearly 1 Million Americans

President Trump to Issue $500 ACA Refund Checks to Nearly 1 Million Americans

President Trump's administration is set to begin sending $500 refund checks to nearly one million Americans starting September 30. These checks are intended for individuals who, according to the administration, were overcharged through the Affordable Care Act's (ACA) federal exchange for health insurance. The Treasury Department will issue these checks, accompanied by letters signed by President Trump, to over 950,000 Americans across 30 states. The White House asserts that the Biden administration collected user fees from health insurance companies, which were passed on to consumers through higher premiums, and that these premiums exceeded the operational costs of HealthCare.gov. President Trump's letter states that this money rightfully belongs to hard-working Americans and is now being returned to them. The initiative comes approximately five weeks before the November midterm elections, amidst public concerns over high costs and affordability.

Medicare unveils 2027 rates for private Medicare, Part D plans

Medicare unveils 2027 rates for private Medicare, Part D plans

Millions of older Americans on private Medicare could see lower monthly prices on their private Medicare plans. Stand-alone drug plans will increase.

Humana Stock Rises Following Barclays Upgrade to 'Overweight'

Humana Stock Rises Following Barclays Upgrade to 'Overweight'

Humana Stock Rises Following Barclays Upgrade to 'Overweight'

Healthcare Industry Faces $265 Billion Waste Due to Fragmented Data Systems, AI Integration Challenged

Healthcare Industry Faces $265 Billion Waste Due to Fragmented Data Systems, AI Integration Challenged

The U.S. healthcare industry is grappling with significant financial waste, estimated at $265.6 billion annually, primarily due to administrative complexity stemming from fragmented and disconnected data systems. This issue hinders the effective scaling of artificial intelligence (AI) and automation initiatives. Despite the sophistication of AI reasoning models, their results remain inconsistent and unreliable when built upon a fragmented data foundation. The problem is exacerbated by organizations acquiring numerous isolated point solutions over decades, each with its own data format and integration requirements, leading to increased technical debt and architectural complexity. The Centers for Medicare & Medicaid Services (CMS) has mandated HL7® FHIR® as an open standard for data architecture to address this fragmentation, aiming to create a unified, computable, and standards-based data infrastructure.

988 is a start. Now we need a place for people in crisis to go | Opinion

988 is a start. Now we need a place for people in crisis to go | Opinion

About 137 million Americans live in a federally designated mental health professional shortage area. We are only meeting roughly 27% of the need.

Pharmacogenomic Testing Advances Personalized Medicine in the U.S. Healthcare System

Pharmacogenomic Testing Advances Personalized Medicine in the U.S. Healthcare System

Pharmacogenomic testing is emerging as a crucial tool in personalized medicine within the U.S. healthcare landscape. This testing involves analyzing a patient's genetic makeup to predict their response to various medications. By examining genetic variations that influence drug metabolism, efficacy, and safety, healthcare providers can gain insights to guide treatment decisions. The goal is to optimize drug therapy and minimize adverse drug reactions, moving away from a one-size-fits-all approach to medication. This field is rapidly evolving due to advancements in genetic sequencing and analysis technologies, drawing significant attention from the healthcare community. The insights derived from these tests enable more informed decision-making regarding drug prescriptions, allowing providers to select medications that are most effective and least hazardous for individual patients based on their unique genetic profiles.