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An Arm and a Leg: The Medicare Episode

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Dan Weissmann
Mon, 11 Mar 2024 09:00:00 +0000

Medicare may sound like an escape from the expensive world of U.S. health insurance, but it’s more complicated, and expensive, than many realize. And decisions seniors make when they sign up for the federal health insurance program can have huge consequences down the road. 

Host Dan Weissmann speaks with Sarah Jane Tribble, KFF Health News’ chief rural health correspondent, about one of the biggest choices seniors must make: whether to enroll in traditional Medicare or the privatized version, Medicare Advantage. 

Then, Weissmann shares practical tips about how soon-to-be seniors can avoid penalties and pick the plan that’s right for them.

Dan Weissmann


@danweissmann

Host and producer of “An Arm and a Leg.” Previously, Dan was a staff reporter for Marketplace and Chicago’s WBEZ. His work also appears on All Things Considered, Marketplace, the BBC, 99 Percent Invisible, and Reveal, from the Center for Investigative Reporting.

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Transcript: The Medicare Episode

Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

Dan: Hey there–

So, one thing we have never talked about on this show? Medicare. You know, that free-health-care thing you may expect to get when you turn 65.

It’s been on a list of things where I’ve been like, “that is TOO big, and TOO complicated. I can’t get my arms around that just now.” 

Especially because: There’s this thing called Medicare Advantage — a kind of privatized version, run by insurance companies? Seems controversial, and REALLY complicated. 

I’ve been like, Maybe someday.

And that someday? That’s today. Or at least, we start today. Mainly because a colleague of mine just did a BUNCH of work that we get to piggyback off of.

Sarah Jane Tribble: my name is Sarah Jane Tribble and I’m Chief Rural Health Correspondent with KFF Health News.

Dan: And as Sarah Jane reported on Medicare, she was surprised by how much she didn’t know. And how much other folks didn’t know either. 

Sarah Jane Tribble: At Thanksgiving, when I was working on some of these stories, I have friends who are nearing retirement. They’re not really close , but they’re close enough to care and they’re avid NPR listeners. And they were like, wait, so what’s the difference between Medicare Advantage and Medicare? And I was like, they should know. 

Dan: Who’s going to tell them? 

Sarah Jane Tribble: Right?

Dan: That’s us, I guess. 

Sarah Jane Tribble: This show will help tell them.

Dan-in-tape: I hope so. I hope so. 

Dan: Because this traditional-Medicare vs Medicare Advantage — it is a high stakes decision, it happens when you first sign up.

And here’s the big thing that Sarah Jane learned: if you sign up for Medicare Advantage, at that point, when you first get on Medicare, you’re pretty much stuck with it. And some people end up with buyer’s remorse. Big time.

And actually, beyond that choice — between Medicare Advantage and what’s called “traditional Medicare” –, there’s literally a whole alphabet soup of other choices you’re gonna need to make. Each with a price tag, and maybe some big trade-offs. 

And there’s been a lot of questionable information that comes at people. TV shows that older folks watch have been full of ads with People Who Were Real Famous in the 1970s.

J.J. Walker: Hi, I’m Jimmy JJ Walker. 

Joe Namath: Hi, I’m Joe Namath. 

William Shatner: William Shatner here with an important message. I’ve been on Medicare for longer than I’ll admit, and it sure has changed. 

Dan: Some of these ads make claims that sound too good to be true

J.J. Walker: And get this, I’m entitled to an extra 100 a month. That’s 1, 200 a year added to my social security check. And I was like, dyn-o-mite!

Dan: Last year, the feds finalized new rules to try and rein in sketchy claims from some ads like these. 

So understanding what’s going on, it’s a big deal. We’ll run down what I’ve learned so far, including some extremely expert guidance. 

Our expert, by the way, set me straight on a bunch of things, including, sadly, this: Medicare isn’t actually the free-health-care thingy some of us hope for.

Sarah Murdoch: Unfortunately, I think a lot of people think, Oh, Medicare is going to be free , it unfortunately is not.

Dan: The question is how much it’s going to cost you– in dollars, and maybe in your choices managing your own health care. And surprise! It’s super complicated.

So by the time we’re done, you’re gonna understand the difference between Medicare Advantage and traditional Medicare — and how to start sorting through the alphabet soup.We’ll also leave you with some solid resources to figure out what your best choice might be when the time comes, either for you or somebody you care about.

Let’s do it.

This is “An Arm and a Leg,” a show about why health care costs so freaking much, and what we can maybe do about it. I’m Dan Weissmann. I’m a reporter. I like a challenge — so the job we’ve chosen here is to take one of the most enraging, terrifying, depressing parts of American life, and bring you something entertaining, empowering, and useful.

OK, when it comes to Medicare, the biggest choice folks have to make is between traditional Medicare — run directly by the government — and Medicare Advantage plans, which are run by private insurance companies. And again, that’s plans, because a bunch of different insurance companies offer different Medicare Advantage plans. 

And last year, Sarah Jane Tribble started hearing from CEOs of rural hospitals.

They were telling her: Medicare Advantage plans are killing us. We’re spending a ton of time and money fighting with these insurance companies to get paid. And sometimes we don’t get paid.

Sarah Jane Tribble: And then I was also hearing about patients showing up at the hospital and these local hospitals saying, “oh, no, we actually don’t take your plan.” And so you’ve got these small town, you know, folks who have only one hospital and a long, you know, large radius. And they would show up and the hospital would be like, “Ah, you’re going to have to pay out of pocket because we don’t take this Medicare Advantage plan.” And the patient, of course, would be like, “but I’m on Medicare, you’re supposed to take care of me.”

Dan: Yeah. Isn’t that deal with Medicare? Everybody accepts it. You get on Medicare, you’re taken care of?

Sarah Jane Tribble: I began wondering, how much does signing up for a Medicare Advantage plan actually affect the care you get?

Dan: And the answer seems like: Maybe a lot. 

A little Google searching turns up a lot of headlines about claims getting denied, and about hospitals dropping Medicare Advantage plans. 

And it also turns up a report from the Inspector General’s office at the federal Department of Health and Human Services. 

And if you’ve got regular insurance, you may be familiar with what’s called “prior authorization.” That’s when your provider needs to get the insurance company’s OK, their authorization, before going ahead with whatever they think you need … a test, a procedure, a prescription. 

And sometimes the insurer issues a denial. They say no.

The Inspector General’s report looked at a random sample of denials by Medicare Advantage plans. They found one out of every eight denials was for care traditional Medicare totally covers. 

Which, you know, as you get older, if you got sick, you could have eight of these requests in a month. 

Sarah Jane started talking with patients.

Sarah Jane Tribble: I called one gentleman in Washington state, and he wanted out of his Medicare Advantage plan and he couldn’t get out.

Dan: That gentleman is Rick Timmins. 

Rick Timmins: I’m a retired veterinarian. I’m living on Whidbey Island in Washington, which is just north and west of Seattle.

Dan: Ooo, wow! So, is your life just a succession of paddling trips …

Rick Timmins: Ha ha ha ha ha ha. 

Dan: and swims in the sound?

Rick Timmins: Yes, sort of. Although the water is a little bit too cold for me to swim in. So, it’s kayaks when we get out into the water.

Dan: Rick signed up for Medicare Advantage in 2016 after attending an informational seminar run by an insurance agent. 

Rick Timmins: … nice guy, and he said, you know, the best thing to do is to get a Medicare Advantage plan because they cover everything, and it’s, it’s far less expensive than traditional Medicare,

Dan: OK, why would that guy say Medicare Advantage is far less expensive than traditional Medicare? I mean, for one, a lot of us think Medicare’s gonna be free. 

And even if it’s not, why should … I mean, how could … one kind of Medicare be more expensive than another? 

We’re gonna have a lot of details on this later, but here let’s just get into the difference between Medicare Advantage and traditional Medicare. Traditional Medicare is run by the government. Government pays all the bills. 

BUT traditional medicare only pays 80 percent of everything and you’re on the hook for the other 20 percent. There’s no out-of-pocket limit. Let’s bring back Sarah Jane Tribble to briefly say what that means: 

Sarah Jane Tribble: You could pay out the wazoo. It could bankrupt you. 

Dan: Out the wazoo. Because you know: Medical bills, hospital bills … they can get into the tens of thousands, hundreds of thousands of dollars. Twenty percent of that is paying out the wazoo. 

To avoid that risk, if you’re on traditional Medicare you basically need another insurance policy — a supplement, often called Medigap — like it covers the gaps that traditional Medicare leaves. 

Some people get Medigap from their old employers. But most people have to pay for it. It can get expensive. 

Medicare Advantage plans, plans run by private insurance companies, DO have an out of pocket limit. You don’t have to buy a supplement. That’s an advantage. 

Also, there are things traditional Medicare doesn’t pay for — like dental care, and glasses, and hearing aids. Medicare Advantage plans generally DO cover those things. 

And as Rick recalls, the insurance agent pushed Medicare Advantage kinda hard.

Rick Timmins: Basically what he said was, yeah, if you want to sign up for traditional Medicare, I can help you for that, but if you want Medicare Advantage, which is a much better program…

Dan: Then sign right here. So Rick did. Fast forward five years. Rick’s wife notices a little bump on his ear. 

Rick Timmins: She said, you should get that looked at. I have a family history of melanoma. My two sisters have had melanoma.

Dan: Rick says he saw his primary care doc, then started trying to get his insurance company’s promise that seeing a specialist would be covered. He says he called and called, over more than six months.

Rick Timmins: It was not a fun time. I mean, I didn’t know what it was, but I knew that it was growing and it was sore and you know, I was frightened. It’s like you can’t think about anything else when you’re wondering about what’s happening with this little lump.

Dan: Rick says when he did get seen, the thing was the size of a dime. They found it was malignant, cut his earlobe off, and scanned his lymph nodes. They were clean, but he spent a year on immunotherapy. Now he says he’s getting scans every six months.

Sarah Jane Tribble asked Rick’s insurance company about all this. They said they wouldn’t comment on his case.

Meanwhile, Rick says he’s had enough of Medicare Advantage. On traditional Medicare, you don’t need anybody’s OK to go see a specialist. You just go. 

But of course to switch to traditional Medicare, Rick would need a supplement, a Medigap policy.

Rick Timmins: Otherwise, uh, you’re just forking out thousands of dollars if you have any issues.

Dan: Because you’re on the hook for 20 percent of everything. No out of pocket limit. Paying out the wazoo.

But Rick doesn’t think he can get a medigap policy. Because in most states — including Washington, where Rick lives — insurance companies don’t have to issue you a Medigap policy if you have pre-existing conditions. 

Not unless you sign up for it when you FIRST enroll in Medicare. 

Rick Timmins: The insurance companies can tell me, no, we don’t want to insure you. You’ve had too many issues. Look, you had a knee replaced. You had cancer. 

Dan: This is what made Rick’s story, and the whole Medicare situation, so striking to Sarah Jane Tribble.

Sarah Jane Tribble: It’s sort of shocking, actually, right? The Affordable Care Act passes and makes it so that everybody with pre-existing conditions can get insurance no matter what, but it leaves out the people who might need that the most, who are 65 and older. 

Dan: Four states have laws that do require Medigap insurers to take everybody. But only four. 

Sarah Jane Tribble: If you’re Rick in Washington state, you could get rejected.

Dan: I talked to someone else who would like do-overs on signing up for Medicare Advantage. In the 1970s, in his 20s, Robert Wolpa was a professional musician, a guitar player. 

Robert Wolpa: Played in bands up and down the west coast. Went to Canada with an Elvis act. It was really a lot of fun. 

Dan: And he worked in call centers for decades. When he turned 65, he says he got inundated with ads and calls and flyers.

Robert Wolpa: I got one of the mailers says have a free dinner on us. And we’ll teach you all about Medicare, the ins and outs of Medicare.

Dan: He went, and got what he thinks of in retrospect as a hard-sell pitch for Medicare Advantage, which he bought. And, over time, he’s gotten disillusioned. 

He says, you know, it’s one thing to have to call to get a pre-authorization or a referral. “Is this doctor covered? No. Oh okay. Which doctor is covered?” It’s a lot of calls. And then there’s the difficulty of getting through the calls.

Robert Wolpa: It got harder and harder and more frustrating, talking to some of these people who didn’t know what they were doing. I mean and I’ve been a call center guy too for most of my life but these poor people. I mean they are so undertrained and underpaid.

Dan: At least, that’s the impression Robert gets, as a guy who spent years working in call centers.

Robert has priced out a Medigap plan. Because he’s got pre-existing conditions — HIV, a pacemaker — it would be expensive: four hundred seventy nine dollars. Which is almost a third of what he gets from social security. 

Robert Wolpa: And I said, okay. Next option. 

Dan: I suggest maybe his work background gives him an advantage in jumping through hoops, like making all those calls: both knowing how to navigate, and having empathy that could help him keep his blood pressure from spiking too hard. He says, yeah, up to a point … For now. 

Robert Wolpa: And I think to myself, you know, I’m 71. I just turned 71 in November and I’m, I’m a little, I’ve got, I’ve got a little of the HIV cognizant crap. Like my, my short term memory is gone.

Dan: After talking with Robert, this part really gave me pause. I mean, dealing with insurance companies and all the attendant hassles is hard work, right?

It’s not the kind of job I’d wish on somebody as they get older and start slowing down. 

And it could be a job that increasing numbers of people are signing up for: Last year the number of people in Medicare Advantage plans became the majority of people on Medicare.

Alright, I may have scared the bejesus out of you. I’m a little scared myself. 

But I’ve got some super-practical information coming your way. I talked with one of THE best people in the country to find out: What should I know BEFORE it’s time to sign up for Medicare?

Turns out the answer is … A LOT. That’s next.

This episode of “An Arm and a Leg” is produced in partnership with KFF Health News. That’s a nonprofit newsroom covering health care in America. Their reporters, like Sarah Jane Tribble, are amazing. I’m honored to work with them.

OK, so, if you want traditional Medicare, you pretty much need to choose it when you first sign up for Medicare. 

And signing up for Medicare turns out to involve a LOT of choices, and a lot of different price tags.

And some big potential pitfalls. It is wild, the things I’ve learned. 

I found maybe the best person in the country to learn from.

Sarah Murdoch: My name is Sarah Murdoch. I’m the Director of Client Services at the Medicare Rights Center, and we’re a national non profit that assists with Really any Medicare issue that you could conceive of and we serve like a massive quantity of people on our helpline, about 20, 000 people in a year. 

Dan: What would you want people to know when they’re like, say, I don’t know, 64, uh, about the choices there? Because I think a lot of us think, like, “Oh, I’m going to turn 65. I’m going to call the federal government or maybe they’ll call me and I never have to think about health insurance again, or healthcare, or you know, paying these ridiculous prices.” And I think that’s not exactly true. Right?

Sarah Murdoch: To start off, they’re not going to call you. 

Dan: And not only do I have to call THEM, I have to do it on time. Apparently, I get a seven month window — like three and a half months on either side of my 65th birthday. And I better not miss it. 

Because if I do, well, number one: I have to wait until the following January to sign up. And till then, I better have some OTHER health insurance. Because no Medicare for me. 

And not only that: When I do sign up, I’m gonna have to pay a penalty. When Sarah told me this, I was like, “are you kidding me?”

Sarah Murdoch: No, I wish I was kidding, but unfortunately, unfortunately not. So yeah, there are very stringent, kind of, enrollment windows that people need to stick to.

Dan: I kind of couldn’t take it all in at once. I was like, “So either I have to wait, or else I have to pay?” Is that it? Sarah’s like, “no, dummy.”

Sarah Murdoch: You would have to wait AND you would have to pay. So, …

Dan: You’re going to charge me for not having Medicare? That sounds awful. 

Sarah Murdoch: I love talking to people like you said when they’re 64 because you can kind of head off the pitfalls before they happen.

Dan: Oh, get this: The penalty is not a one-time late fee. It bumps up what you pay for the rest of your life. 

Holy crap! I had done some homework before talking with Sarah, but I had not seen that one coming at all. So yeah. Don’t miss that deadline! And about the rest, the part I thought I’d done my homework on, boy did Sarah fill in a lot of blanks.

So, just to get started, here’s the big picture: Medicare is alphabet soup. There’s part A, that covers hospital bills. There’s part B, that covers doctor visits. And there’s part D, for drugs.

What’s part C, you’re asking? Oh, that’s Medicare Advantage. If you’ve got that, it basically takes over for A, B and– a lot of the time, D. 

And let’s say you don’t want to go with Medicare Advantage when you first sign up for Medicare, because for most people, this is like your one shot at getting traditional Medicare, accepted just about everywhere, no questions asked.

Then, you’ll need to buy a Medigap supplement, so you don’t end up paying out the wazoo if you run into health problems– because traditional Medicare only pays 80 percent.

But no matter what you pick– Medicare Advantage or traditional Medicare … it’s gonna cost you. As we heard from Sarah right at the top of this episode…

Sarah Murdoch: I think a lot of people think, Oh, Medicare is going to be free, it unfortunately is not.

Dan: Yeah, so each part has its own price tag … Or tags. Sarah walked me through it.

And actually, the very first step involves some GOOD news.

Sarah Murdoch: Part A, which is hospital and inpatient coverage is free for most people. 

Dan: So, if you’ve paid into social security and medicare for ten years, that’s you. So, great.

And unfortunately, that’s where the easy, simple part… ends. 

Next, we move on to Part B — doctor bills. Outpatient stuff.

Sarah Murdoch: Part B has a monthly premium, uh, of $174… let me just get the exact, it’s $174 and change,

Dan: A hundred seventy-four dollars and seventy cents. 

And important to note: Picking a Medicare Advantage plan does NOT mean you skip paying this part B premium, this 174 dollars and seventy cents. It applies to pretty much everybody.

And folks with higher incomes — starting at 103,000 dollars — can pay more. 

OK, that’s part B. Doctor visits. On to part D for drugs. 

Fun fact: This is 100 percent run by private insurance companies, actually. 

Which, among other things, means it involves shopping for a plan. Every year.

Sarah Murdoch: Those plans and their premiums change year to year. In New York, like, we would see them ranging from anywhere from like $3 monthly premium to $120. So all over the place.

Dan: $3 sounds good, but I’m guessing there’s a catch.

Sarah Murdoch: Yes, so not every plan is identical. 

Dan: Some Part D plans cover more drugs than others. Some leave you paying more for the drugs they do cover. Which one is a good deal will depend on what meds you need.

Ugh, sounds fun, right? Well, Sarah tells me there’s actually a bit of good news here, because we’re not on our own with this.

Sarah Murdoch: Medicare does, on medicare.gov, have a really great tool called “plan finder” where people can enter their medications. It sort of matches up your medications with the plans that cover them in the most affordable way. 

Dan: This is a huge relief, because shopping on my own? Yeesh. It looks like there are 21 different Part D plans in my area, so comparing all of them would be a big job. 

OK! Now I’ve got Parts A, B, and D. I’m on the hook for, well start with $174.70, plus however much for drugs. 

And if I still want traditional Medicare — just about everyone takes it, hardly any pre-authorizations to worry about — I still need a Medigap plan. Also called a supplement. And, again, now I’m shopping for insurance from private companies. 

And guess what? We’ve got a whole new bowl of alphabet soup! 

Sarah Murdoch: Yeah. So there’s 10 Medigaps. They all have a letter. 

Dan: Yeah and each letter has its own set of benefits and exclusions —some have higher deductibles, others cover some extras, but they’re all supposed to protect you from paying out the wazoo.

So for example, Plan G is the most comprehensive, and the most expensive. And of course, once I’ve picked a letter, I’m sifting through however-many companies offer any given plan in my area. 

Where I live, in Illinois, it looks like there are 57 Plan G’s on offer. Prices: A hundred thirty bucks to four sixty four. 

But here’s another little bit of good news for us. Because Sarah has a super important tip.

Sarah Murdoch: I think it is very important for people to keep in mind there that all the G’s are identical, right? A G offered by company 1 that’s $500, versus the G offered by company 2 that’s $300, have identical benefits, so there’s no reason to pick the, um, more expensive. 

Dan: I ask Sarah: Wait. How are any of these companies getting away with charging more for the exact same thing? Like, why would anybody ever choose the more expensive one? She’s like, maybe they just don’t know any better.

Sarah Murdoch: Maybe they had that company, you know, when they were working and they have, you know, preconceived notions about it.

Dan: So when people call the helpline, Sarah and her colleagues tell them …

Sarah Murdoch: Pick one that’s the most affordable. Don’t make some other selection for whatever reason you might imagine in your head.

Dan: So of course it turns out in the case of Plan G, which just happens to be the example Sarah’s using, there IS a caveat: In some states, there are Plan G’s sold with a high deductible and lower premiums. Okay, more to watch out for. But in general, this is some really good advice right here.

All of this leaves me with a big take-away: 

Medicare is not free. There’s that 174 seventy for the Part B premium … and then you may be looking at a bunch of money on top of that, for a Medigap plan. 

Or, if you go with Medicare Advantage and avoid paying for a Medigap plan, you are looking at dealing with private health insurance companies that we all love so much.

All the shopping for a plan:  “Do I get an HMO? A PPO? What’s the difference again?” 

And then all the questions, all the run-arounds, all year round: “Is my doctor covered? Is my doctor still covered this year? Is the company gonna approve the care my doctor says I need? If they don’t, what the hell am I gonna do?”

All of it left my colleague Sarah Jane Tribble pretty ticked off.

Sarah Jane Tribble: The thing that blew my mind is how expensive it is to have any form of Medicare, right? It’s not a free ticket for your health care. This is to me, the most outrageous thing that you’re going into retirement, you’ve lived your life, and America is supposed to give you this promise of Medicare, and then the promise is actually hundreds of dollars a month.

Dan: Or you can save some money by signing up for Medicare Advantage, and hope it works out for you. 

And hey: It does work for some people. My mom’s on a Medicare Advantage plan — she’s 93 and definitely sees a few doctors — and she’s got no complaints. 

Here’s Sarah Murdoch from the Medicare Rights Center:

Sarah Murdoch: When people ask, I think often, like, which one is better? It’s like, that’s, that’s not … I can’t answer that because people’s needs are different. People’s doctors are different. Where they live and their access to different services might be different. If you’re in a plan that all your doctors take, then that’s great. You can save some money that way too on those premiums.

Dan: And hope the insurance company doesn’t change the deal next year. And that your doctors don’t decide to leave the plan. 

OK, I’m not trying to freak you out — or myself. And I actually have some good news, thanks to Sarah Murdoch. 

Because: We’ve covered a lot of ground on what you should know about Medicare. But holy crap, there is SO much more to know. Medigap plans are regulated by states– that’s 50 different setups right there. Not to mention the ten different flavors of Medigap. And all the kajillion and one different Medicare Advantage plans out there. 

And there’s deals we haven’t talked about too. Some people with low incomes qualify for Medicaid, which kind of serves as a Medigap. Some people can get government subsidies to cover that Medicare Part B premium. And, again, all of this is state-by-state: 50 different deals.

So if you’re looking at actually signing up for Medicare, you’re gonna have a lot more questions than I can start to answer here. 

And the good news is: You don’t have to go to an insurance broker, like Rick and Rob did, and hope they steer you right instead of, you know, chasing a higher commission.

Sarah Murdoch says every state has an agency you can call. They’re called SHIPS — for State Health Insurance Assistance Programs — the A is silent, I guess. And their job is to give unbiased advice. 

If you’re in New York, you might even end up talking with Sarah or one of her colleagues.

Sarah Murdoch: The SHIPS don’t get anything. They don’t have any financial incentive. We participate in the New York ship, like I don’t care what plan you pick. I just want to help you pick something that is going to work for you. And that may be original Medicare with a Medigap and Part D. It might be a Medicare Advantage plan. It might be, you know, Medicare and Medicaid. 

Dan: So if this episode is pitched at someone who’s at or approaching age 64, the bottom line is like, go get on a ship. Go sail on a ship. Is that right? 

Sarah Murdoch: Yeah. There’s a central website, shiphelp. org, where you can just click on your state and it will kind of direct you to the phone number to call. So, they’re there as a resource.

This was a LOT. Let’s just review:

First: Medicare isn’t free. Got it.

Second: Don’t forget to sign up on time! You could end up paying a late fee every month for the rest of your life.

“An Arm and a Leg” is a co-production of KFF Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and X, formerly known as Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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By: Dan Weissmann
Title: An Arm and a Leg: The Medicare Episode
Sourced From: kffhealthnews.org/news/podcast/the-medicare-episode/
Published Date: Mon, 11 Mar 2024 09:00:00 +0000

Kaiser Health News

States Brace for Reversal of Obamacare Coverage Gains Under Trump’s Budget Bill

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kffhealthnews.org – Julie Appleby, KFF Health News – 2025-07-03 14:43:00


The tax and spending bill pushed by President Trump includes provisions that shorten ACA enrollment periods, increase paperwork, and raise premiums, threatening coverage gains from the Affordable Care Act. Particularly impacted are the 19 states running their own ACA exchanges, where automatic reenrollment would end, potentially causing 30-50% enrollment losses. Combined with the likely expiration of enhanced pandemic premium subsidies, premiums could rise 75% on average next year. Supporters cite fraud reduction, but many analysts warn these changes could push 4-6 million people out of Marketplace plans, increase the uninsured rate, and leave insurers with smaller, sicker pools and higher prices.


Shorter enrollment periods. More paperwork. Higher premiums. The sweeping tax and spending bill pushed by President Donald Trump includes provisions that would not only reshape people’s experience with the Affordable Care Act but, according to some policy analysts, also sharply undermine the gains in health insurance coverage associated with it.

The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges.

Many of those states fear that the additional red tape — especially requirements that would end automatic reenrollment — would have an outsize impact on their policyholders. That’s because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal healthcare.gov marketplace.

“The federal marketplace always had a message of, ‘Come back in and shop,’ while the state-based markets, on average, have a message of, ‘Hey, here’s what you’re going to have next year, here’s what it will cost; if you like it, you don’t have to do anything,’” said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director with the Manatt Health consulting group.

Millions — perhaps up to half of enrollees in some states — may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule from the Trump administration and the likely expiration at year’s end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year. That’s starting to happen already, based on some early state rate requests for next year, which are hitting double digits.

“We estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,” said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees this year, a record.

Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the “One Big Beautiful Bill,” could undo inroads made in the nation’s uninsured rate, which dropped by about half from the time most of the ACA’s provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data.

Premiums would rise along with the uninsured rate, because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage — and are thus less expensive — would not.

After a dramatic all-night session, House Republicans passed the bill, meeting the president’s July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration.

The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round.

In addition, automatic reenrollment, used by more than 10 million people for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently.

That’s a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era’s “lax verification requirements.”

He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers’ being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers.

In testimony to Congress on June 25, Blase wrote that “this simple step will close a massive loophole and significantly reduce improper enrollment and spending.”

States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal healthcare.gov.

The state-run marketplaces credit their additional security measures and tighter control over broker access than healthcare.gov for the relative lack of problems.

“If you look at California and the other states that have expanded their Medicaid programs, you don’t see that kind of fraud problem,” said Jessica Altman, executive director of Covered California, the state’s Obamacare marketplace. “I don’t have a single case of a consumer calling Covered California saying, ‘I was enrolled without consent.’”

Such rollovers are common with other forms of health insurance, such as job-based coverage.

“By requiring everyone to come back in and provide additional information, and the fact that they can’t get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,” said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data. KFF is a health information nonprofit that includes KFF Health News.

Federal data shows about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF.

States do check income and other eligibility information for all enrollees — including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they’ve experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period.

“We have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,” Altman said.

If flagged for mismatched data, applicants are asked for additional information. Under current law, “we have 90 days for them to have a tax credit while they submit paperwork,” Altman said.

That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information.

A white paper written for Capital Policy Analytics, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes.

While “tighter verification can curb improper enrollments,” the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, “would push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,” wrote free market economists Ike Brannon and Anthony LoSasso.

“Insurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,” they wrote.

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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The post States Brace for Reversal of Obamacare Coverage Gains Under Trump’s Budget Bill appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content presents a critique of Republican-led changes to the Affordable Care Act, emphasizing potential negative impacts such as increased premiums, reduced enrollment, and the erosion of coverage gains made under the ACA. It highlights the perspective of policy analysts and state officials who express concern over these measures, while also presenting conservative viewpoints, particularly those focusing on fraud reduction. Overall, the tone and framing lean toward protecting the ACA and its expansions, which traditionally aligns with Center-Left media analysis.

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Kaiser Health News

Dual Threats From Trump and GOP Imperil Nursing Homes and Their Foreign-Born Workers

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kffhealthnews.org – Jordan Rau, KFF Health News – 2025-06-26 04:00:00


In Alexandria, Virginia, Rev. Donald Goodness, 92, is cared for by many foreign-born nurses like Jackline Conteh from Sierra Leone, who vigilantly manages his celiac disease needs. The long-term care industry relies heavily on immigrants, with 28% of direct care workers being foreign-born. However, President Trump’s 2024 immigration crackdown, including rescinded protections and revoked work permits for refugees, threatens staffing levels. Coupled with proposed Medicaid spending cuts, nursing homes face worsening shortages and quality challenges. Many immigrant caregivers fear deportation, risking a crisis in elder care as demand rises with America’s aging population.


In a top-rated nursing home in Alexandria, Virginia, the Rev. Donald Goodness is cared for by nurses and aides from various parts of Africa. One of them, Jackline Conteh, a naturalized citizen and nurse assistant from Sierra Leone, bathes and helps dress him most days and vigilantly intercepts any meal headed his way that contains gluten, as Goodness has celiac disease.

“We are full of people who come from other countries,” Goodness, 92, said about Goodwin House Alexandria’s staff. Without them, the retired Episcopal priest said, “I would be, and my building would be, desolate.”

The long-term health care industry is facing a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending. The industry is highly dependent on foreign workers: More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies.

But in January, the Trump administration rescinded former President Joe Biden’s 2021 policy that protected health care facilities from Immigration and Customs Enforcement raids. The administration’s broad immigration crackdown threatens to drastically reduce the number of current and future workers for the industry. “People may be here on a green card, and they are afraid ICE is going to show up,” said Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults.

Existing staffing shortages and quality-of-care problems would be compounded by other policies pushed by Trump and the Republican-led Congress, according to nursing home officials, resident advocates, and academic experts. Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid. Care for 6 in 10 residents is paid for by Medicaid, the state-federal health program for poor or disabled Americans.

“We are facing the collision of two policies here that could further erode staffing in nursing homes and present health outcome challenges,” said Eric Roberts, an associate professor of internal medicine at the University of Pennsylvania.

The industry hasn’t recovered from covid-19, which killed more than 200,000 long-term care facility residents and workers and led to massive staff attrition and turnover. Nursing homes have struggled to replace licensed nurses, who can find better-paying jobs at hospitals and doctors’ offices, as well as nursing assistants, who can earn more working at big-box stores or fast-food joints. Quality issues that preceded the pandemic have expanded: The percentage of nursing homes that federal health inspectors cited for putting residents in jeopardy of immediate harm or death has risen alarmingly from 17% in 2015 to 28% in 2024.

In addition to seeking to reduce Medicaid spending, congressional Republicans have proposed shelving the biggest nursing home reform in decades: a Biden-era rule mandating minimum staffing levels that would require most of the nation’s nearly 15,000 nursing homes to hire more workers.

The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care. The Census Bureau has projected the number of people 65 and older would grow from 63 million this year to 82 million in 2050.

In an email, Vianca Rodriguez Feliciano, a spokesperson for the Department of Health and Human Services, said the agency “is committed to supporting a strong, stable long-term care workforce” and “continues to work with states and providers to ensure quality care for older adults and individuals with disabilities.” In a separate email, Tricia McLaughlin, a Department of Homeland Security spokesperson, said foreigners wanting to work as caregivers “need to do that by coming here the legal way” but did not address the effect on the long-term care workforce of deportations of classes of authorized immigrants.

Goodwin Living, a faith-based nonprofit, runs three retirement communities in northern Virginia for people who live independently, need a little assistance each day, have memory issues, or require the availability of around-the-clock nurses. It also operates a retirement community in Washington, D.C. Medicare rates Goodwin House Alexandria as one of the best-staffed nursing homes in the country. Forty percent of the organization’s 1,450 employees are foreign-born and are either seeking citizenship or are already naturalized, according to Lindsay Hutter, a Goodwin spokesperson.

“As an employer, we see they stay on with us, they have longer tenure, they are more committed to the organization,” said Rob Liebreich, Goodwin’s president and CEO.

Jackline Conteh spent much of her youth shuttling between Sierra Leone, Liberia, and Ghana to avoid wars and tribal conflicts. Her mother was killed by a stray bullet in her home country of Liberia, Conteh said. “She was sitting outside,” Conteh, 56, recalled in an interview.

Conteh was working as a nurse in a hospital in Sierra Leone in 2009 when she learned of a lottery for visas to come to the United States. She won, though she couldn’t afford to bring her husband and two children along at the time. After she got a nursing assistant certification, Goodwin hired her in 2012.

Conteh said taking care of elders is embedded in the culture of African families. When she was 9, she helped feed and dress her grandmother, a job that rotated among her and her sisters. She washed her father when he was dying of prostate cancer. Her husband joined her in the United States in 2017; she cares for him because he has heart failure.

“Nearly every one of us from Africa, we know how to care for older adults,” she said.

Her daughter is now in the United States, while her son is still in Africa. Conteh said she sends money to him, her mother-in-law, and one of her sisters.

In the nursing home where Goodness and 89 other residents live, Conteh helps with daily tasks like dressing and eating, checks residents’ skin for signs of swelling or sores, and tries to help them avoid falling or getting disoriented. Of 102 employees in the building, broken up into eight residential wings called “small houses” and a wing for memory care, at least 72 were born abroad, Hutter said.

Donald Goodness grew up in Rochester, New York, and spent 25 years as rector of The Church of the Ascension in New York City, retiring in 1997. He and his late wife moved to Alexandria to be closer to their daughter, and in 2011 they moved into independent living at the Goodwin House. In 2023 he moved into one of the skilled nursing small houses, where Conteh started caring for him.

“I have a bad leg and I can’t stand on it very much, or I’d fall over,” he said. “She’s in there at 7:30 in the morning, and she helps me bathe.” Goodness said Conteh is exacting about cleanliness and will tell the housekeepers if his room is not kept properly.

Conteh said Goodness was withdrawn when he first arrived. “He don’t want to come out, he want to eat in his room,” she said. “He don’t want to be with the other people in the dining room, so I start making friends with him.”

She showed him a photo of Sierra Leone on her phone and told him of the weather there. He told her about his work at the church and how his wife did laundry for the choir. The breakthrough, she said, came one day when he agreed to lunch with her in the dining room. Long out of his shell, Goodness now sits on the community’s resident council and enjoys distributing the mail to other residents on his floor.

“The people that work in my building become so important to us,” Goodness said.

While Trump’s 2024 election campaign focused on foreigners here without authorization, his administration has broadened to target those legally here, including refugees who fled countries beset by wars or natural disasters. This month, the Department of Homeland Security revoked the work permits for migrants and refugees from Cuba, Haiti, Nicaragua, and Venezuela who arrived under a Biden-era program.

“I’ve just spent my morning firing good, honest people because the federal government told us that we had to,” Rachel Blumberg, president of the Toby & Leon Cooperman Sinai Residences of Boca Raton, a Florida retirement community, said in a video posted on LinkedIn. “I am so sick of people saying that we are deporting people because they are criminals. Let me tell you, they are not all criminals.”

At Goodwin House, Conteh is fearful for her fellow immigrants. Foreign workers at Goodwin rarely talk about their backgrounds. “They’re scared,” she said. “Nobody trusts anybody.” Her neighbors in her apartment complex fled the U.S. in December and returned to Sierra Leone after Trump won the election, leaving their children with relatives.

“If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents?” Conteh asked. “What will become of our old people that we’re taking care of?”

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post Dual Threats From Trump and GOP Imperil Nursing Homes and Their Foreign-Born Workers appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content primarily highlights concerns about the impact of restrictive immigration policies and Medicaid spending cuts proposed by the Trump administration and Republican lawmakers on the long-term care industry. It emphasizes the importance of immigrant workers in healthcare, the challenges that staffing shortages pose to patient care, and the potential negative effects of GOP policy proposals. The tone is critical of these policies while sympathetic toward immigrant workers and advocates for maintaining or increasing government support for healthcare funding. The framing aligns with a center-left perspective, focusing on social welfare, immigrant rights, and concern about the consequences of conservative economic and immigration policies without descending into partisan rhetoric.

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Kaiser Health News

California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch

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kffhealthnews.org – Sarah Kwon – 2025-06-25 04:00:00


California lawmakers are set to delay the state’s new IVF insurance coverage law, originally effective July 1, to January 2026. Governor Gavin Newsom requested the postponement to resolve coverage details like embryo storage and donor materials. The law mandates large employers’ health plans to cover infertility diagnosis and treatment, including up to three egg retrievals and unlimited embryo transfers, benefiting nine million people, including same-sex couples and single parents. The delay has caused uncertainty and frustration among patients and employers. If not delayed, enforcement begins July 1, but most employers renew contracts in January, delaying coverage start anyway. Lawmakers will vote soon.


California lawmakers are poised to delay the state’s much-ballyhooed new law mandating in vitro fertilization insurance coverage for millions, set to take effect July 1. Gov. Gavin Newsom has asked lawmakers to push the implementation date to January 2026, leaving patients, insurers, and employers in limbo.

The law, SB 729, requires state-regulated health plans offered by large employers to cover infertility diagnosis and treatment, including IVF. Nine million people will qualify for coverage under the law. Advocates have praised the law as “a major win for Californians,” especially in making same-sex couples and aspiring single parents eligible, though cost concerns limited the mandate’s breadth.

People who had been planning fertility care based on the original timeline are now “left in a holding pattern facing more uncertainty, financial strain, and emotional distress,” Alise Powell, a director at Resolve: The National Infertility Association, said in a statement.

During IVF, a patient’s eggs are retrieved, combined with sperm in a lab, and then transferred to a person’s uterus. A single cycle can total around $25,000, out of reach for many. The California law requires insurers to cover up to three egg retrievals and an unlimited number of embryo transfers.

Not everyone’s coverage would be affected by the delay. Even if the law took effect July 1, it wouldn’t require IVF coverage to start until the month an employer’s contract renews with its insurer. Rachel Arrezola, a spokesperson for the California Department of Managed Health Care, said most of the employers subject to the law renew their contracts in January, so their employees would not be affected by a delay.

She declined to provide data on the percentage of eligible contracts that renew in July or later, which would mean those enrollees wouldn’t get IVF coverage until at least a full year from now, in July 2026 or later.

The proposed new implementation date comes amid heightened national attention on fertility coverage. California is now one of 15 states with an IVF mandate, and in February, President Donald Trump signed an executive order seeking policy recommendations to expand IVF access.

It’s the second time Newsom has asked lawmakers to delay the law. When the Democratic governor signed the bill in September, he asked the legislature to consider delaying implementation by six months. The reason, Newsom said then, was to allow time to reconcile differences between the bill and a broader effort by state regulators to include IVF and other fertility services as an essential health benefit, which would require the marketplace and other individual and small-group plans to provide the coverage.

Newsom spokesperson Elana Ross said the state needs more time to provide guidance to insurers on specific services not addressed in the law to ensure adequate and uniform coverage. Arrezola said embryo storage and donor eggs and sperm were examples of services requiring more guidance.

State Sen. Caroline Menjivar, a Democrat who authored the original IVF mandate, acknowledged a delay could frustrate people yearning to expand their families, but requested patience “a little longer so we can roll this out right.”

Sean Tipton, a lobbyist for the American Society for Reproductive Medicine, contended that the few remaining questions on the mandate did not warrant a long delay.

Lawmakers appear poised to advance the delay to a vote by both houses of the legislature, likely before the end of June. If a delay is approved and signed by the governor, the law would immediately be paused. If this does not happen before July 1, Arrezola said, the Department of Managed Health Care would enforce the mandate as it exists. All plans were required to submit compliance filings to the agency by March. Arrezola was unable to explain what would happen to IVF patients whose coverage had already begun if the delay passes after July 1.

The California Association of Health Plans, which opposed the mandate, declined to comment on where implementation efforts stand, although the group agrees that insurers need more guidance, spokesperson Mary Ellen Grant said.

Kaiser Permanente, the state’s largest insurer, has already sent employers information they can provide to their employees about the new benefit, company spokesperson Kathleen Chambers said. She added that eligible members whose plans renew on or after July 1 would have IVF coverage if implementation of the law is not delayed.

Employers and some fertility care providers appear to be grappling over the uncertainty of the law’s start date. Amy Donovan, a lawyer at insurance brokerage and consulting firm Keenan & Associates, said the firm has fielded many questions from employers about the possibility of delay. Reproductive Science Center and Shady Grove Fertility, major clinics serving different areas of California, posted on their websites that the IVF mandate had been delayed until January 2026, which is not yet the case. They did not respond to requests for comment.

Some infertility patients confused over whether and when they will be covered have run out of patience. Ana Rios and her wife, who live in the Central Valley, had been trying to have a baby for six years, dipping into savings for each failed treatment. Although she was “freaking thrilled” to learn about the new law last fall, Rios could not get clarity from her employer or health plan on whether she was eligible for the coverage and when it would go into effect, she said. The couple decided to go to Mexico to pursue cheaper treatment options.

“You think you finally have a helping hand,” Rios said of learning about the law and then, later, the requested delay. “You reach out, and they take it back.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

USE OUR CONTENT

This story can be republished for free (details).

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—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.

This article first appeared on KFF Health News and is republished here under a Creative Commons license.

The post California’s Much-Touted IVF Law May Be Delayed Until 2026, Leaving Many in the Lurch appeared first on kffhealthnews.org



Note: The following A.I. based commentary is not part of the original article, reproduced above, but is offered in the hopes that it will promote greater media literacy and critical thinking, by making any potential bias more visible to the reader –Staff Editor.

Political Bias Rating: Center-Left

This content is presented in a factual, balanced manner typical of center-left public policy reporting. It focuses on a progressive healthcare issue (mandated IVF insurance coverage) favorably highlighting benefits for diverse family structures and individuals, including same-sex couples and single parents, which often aligns with center-left values. At the same time, it includes perspectives from government officials, industry representatives, opponents, and patients, offering a nuanced view without overt ideological framing or partisan rhetoric. The emphasis on healthcare access, social equity, and patient impact situates the coverage within a center-left orientation.

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