The Healthcare Labyrinth

The Trump Administration is on a VBC reform model fury. It deserves credit but there are potholes ahead on its reform map. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the Trump administration's VBC reform model fury. It deserves credit but there are potholes ahead on its reform map. Key Takeaways: Medicare FFS is badly in need of reform and CMS has been introducing VBC payment models for a number of years. The Trump administration has been on a model fury, seeking to set its mark on healthcare reform. It is introducing reforms leveraging technology and expanding VBC payments. But the model fatigue of the past is setting in again with numerous new models and aggressive timeframes. The tech-enabled ACCESS model was extended to obtain more tech company participants. The ACO LEAD model may not get the volume CMS hoped for, either. The GLP-1 BALANCE model has been paused because too few plans expressed interest. BALANCE holds great promise, short-term costs in return for long-term savings and better health. But it comes at a tough time for plans, which are in the midst of a financial recovery. The Trump administration's vision is commendable but may need some tactical adjustment. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Medicare Advantage critics pound the program with shoddy analyses. We showcase the good ones on quality, value, and savings. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc pushes back on the Medicare Advantage critics, who pound the program with shoddy analyses. He showcases the good studies showing MA's quality, value, and savings. Key Takeaways: Medicare Advantage's critics pound the program with shoddy analyses. But numerous studies show the quality, value, and savings in MA. MedPAC's studies on MA's favorable selection are easily debunked as there is great evidence MA serves some of the most vulnerable. So-called overpayments in risk adjustment have also been going away due to reforms. Studies show that MA means much lower utilization among beneficiaries through managed care and care management. Others show that enrollees in MA have much lower out-of-pocket costs. Despite attacks by critics, still more analyses show overall lower per-beneficiary costs of MA compared with FFS. MA also has a halo effect over overall Medicare spending. The greater the MA penetration, the lower cost trends in Medicare as a whole.  Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

The final 2027 Medicare Advantage Rate Announcement provided some relief to a still displeased industry.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the final 2027 Medicare Advantage Rate Announcement. It provided some relief to a still displeased industry.   Key Takeaways: Medicare Advantage (MA) plans got a bit of relief from CMS initial proposal of a 0.09% rate hike in 2027. The final adjustment will be 2.48%. CMS gave in a bit to the industry and pulled back on another proposed risk adjustment model change. It will follow through on some risk adjustment reform by barring unlinked charts (those not connected to an actual provider encounter) in most cases. The rate hike is far below what has been seen in terms of utilization. The hike will mean about $13 billion in new dollars to MA plans, up from under $1 billion proposed. But because most plans do not have aggressive risk adjustment practices, most plans will see an increase closer to 4%. Big plans will bear the burden of most of the unlinked chart reform. The 2027 modest hike is yet another sign that CMS will be stingier on rate dollars in the future.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The final 2027 Medicare Advantage and Part D rule cemented some major changes in Star Ratings that will have far-reaching revenue impacts.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the final 2027 Medicare Advantage and Part D rule. It cemented some major changes in Star Ratings that will have far-reaching revenue impacts.   Key Takeaways: The 2027 Medicare Advantage and Part D rule was finalized with major Star Ratings changes. The EHO4all health equity reward was retroactively rescinded, and the Reward Factor will be kept. Thirteen of 14 measure retirements were finalized, most of which are easy-to-hit operational measures. A new Depression Screening measure was adopted as well. The effect of the measure changes means clinical measures now are weighted almost half of overall star ratings, with CAHPS and HOS measures over a third. At least 25% of contracts are expected to lose a half Star rating, with others seeing their performance drop to put higher ratings out of reach. Other reforms adopted include repealing many health equity mandates, reining in and reforming supplemental benefits, and codifying many Part D changes.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Since the feds won't act, states are increasingly passing healthcare reform legislation to control costs.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses a series of state healthcare laws and bills. Since the feds won't act, states are increasingly passing healthcare reform legislation to control costs.   Key Takeaways: Trump 47 has pushed forward on a series of healthcare regulatory reforms. Kudos, but Congress refuses to truly act. Therefore, states are increasingly getting into the healthcare reform game. While states are preempted on self-insured and Medicare coverage, they are getting creative to impact price and reduce costs. Many are pushing through hospital price caps in various forms. Other states have set up statewide accountability costs to limit overall healthcare cost growth. Many states have passed transparency laws. Reform at the state level is in progressive as well as conservative states. Increasingly states see the problem and do not view controlling price negatively. But Congress must act to have true impact and so we don't have a patchwork system. Site neutral payments, uniform pricing, and addressing consolidation are among the reforms I view as crucial.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

While some may disagree with the strategies, there is little question Dr. Oz is carrying out a revolution at CMS. Change is needed.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses how there is little question Dr. Oz is carrying out a revolution at CMS. While some may disagree with the strategies, change is needed.   Key Takeaways: There is little question that the Trump 47 CMS is very different than Trump 45 and Biden. If Trump 45 tested ideas, Trump 47 is executing on them. Leveraging technology in healthcare is top of mind for CMS Administrator Dr. Oz. Quality is poor in healthcare and Oz wants to change that so as to reduce costs. Oz rightly notes that people who do not seek care can be the most expensive. Oz is very focused on reducing drug prices and the Trump administration has made remarkable progress. CMS also continues with value-based care and there is a proliferation of models. Aspects of the CMS initiatives are controversial and will have fallout. But it is hard to argue change is not needed.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The 2026 midterms will be about affordability, especially regarding healthcare. The Democrats almost assuredly will win back the House. The GOP's hold in the Senate could be in question.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses how the 2026 midterms will be about affordability, especially regarding healthcare. The Democrats almost assuredly will win back the House. The GOP's hold in the Senate could be in question.   Key Takeaways: Affordability will dominate the 2026 midterms. Healthcare affordability is very much on Americans' minds according to polls. Even popular presidents' parties usually lose seats in Congress during midterms. There are just a few exceptions. The generic congressional ballot—a key measure of national sentiment—currently favors Democrats by about five points. With affordability dominating the headlines as it did in 2024, the GOP looks very vulnerable. The House almost assuredly will fall to the Democrats, with either a tight margin or a more comfortable one. Several months ago, the GOP seemed to have a lock on maintaining their hold of the Senate. But that is now somewhat in doubt. If the Democrats take even one house, Donald Trump immediately becomes a lame duck. To effect change, he would have to go even more in on regulations, executive orders, and government fiat.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Yes, Medicare Advantage is struggling, but it remains a key social safety net program. It just needs less biased assessments and better advocates.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses that Medicare Advantage is struggling, but it remains a key social safety net program. It just needs less biased assessments and better advocates.   Key Takeaways: Medicare Advantage turned 25 recently and is facing great financial troubles. CMS has proposed tight rates, restrictions on prior authorizations, risk adjustment reforms, and Star rating changes. This has led to major retrenchment, with reduced benefits, products, and footprints. MA growth has slowed but it still grew year over year and during open enrollment. MedPAC has been arguing MA is overpaid for years but relies on outdated data and dubious assumptions. This has undermined MA. Some overpayments existed, but much of it went to the biggest health plans that used aggressive coding. A bipartisan duo of former HHS secretaries came to the defense of MA recently, saying CMS and Capitol Hill have gone too far. Let's hope the defense of MA messages sink in The MA program is an important safety net and its death is greatly exaggerated.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Trying to make sense of the recent PBM reforms and their significance? I map them in this podcast and what it really means? It is game-changing. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc maps all the recent PBM and drug price reforms and tells you about their significance? It is game-changing. Key Takeaways: The recent FFY 2026 Appropriations Bill had major PBM reforms. They included 100% rebate pass-through and transparency and reporting in the employer market. In Medicare Part D, PBMs must adopt flat-fee compensation that is de-linked from rebates and utilization. Important reporting and transparency in Part D as well. Group purchasing reform could be next on lawmakers' list. A Federal Trade Commission settlement with Cigna's Express Scripts PBM has many similar reforms. Express Scripts is also adopting a brand net pricing model that will run in parallel with a traditional rebate model. Various initiatives from the Trump administration will also dramatically impact drug price. These include reforms of the drug channel and most-favored nation pricing. The developments are game-changing, but it will take time for reforms to set in and impact every line of business. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Showing Medicare Advantage's value, the sky did not fall on MA, but the earth shifted on the program. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the 2026 Medicare Advantage open enrollment. Showing Medicare Advantage's value, the sky did not fall on MA, but the earth shifted on the program. Key Takeaways:  Many analysts predicted a major contraction during open enrollment, but the Medicare Advantage program still grew. It grew 874K year over year and about 115K during open enrollment. MA has grown almost 50% — 11.9 million lives – since 2020. This shows the overall value of MA compared with traditional Medicare fee-for-service (FFS). Still growth has come way down in 2025 and 2026, which shows the financial stress in the program. Big plans did not fare well in open enrollment, losing 328K lives. Except for Humana, which grew about 1.2M, most big MA plans wanted to contract. Non-Big MA plans added 443,000 lives during open enrollment, including the insurtechs by 320K lives. SNPs grew 647,000 lives year over year -- 259,000 of that during open enrollment. PPOs saw major contraction in terms of offerings and enrollment. PPOs were down year over year by 103K, while HMOs grew 937K. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

The 2027 ACA Exchange rule will create some seismic changes in healthcare. Is it a structural reset or risky gamble? About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the 2027 ACA Exchange rule. It will create some seismic changes in healthcare. Is it a structural reset or risky gamble? Key Takeaways:  The 2027 ACA Exchanges build on the One Big Beautiful bill with more seismic changes to the Affordable Care Act and the Exchanges. The Obama and Biden administrations were hopelessly devoted to the rich benefit and subsidy program. The COVID enhanced subsidies made Democrats even more devoted. But with or without the enhanced subsides, while many became insured, high premiums, deductibles, and cost-sharing actually created an underinsured problem. Trump 45 began some changes, but Trump 47 is structurally resetting to and emphasis on skinner coverage. Existing changes promote ICHRAs, HSAs, and DPCs. The rule proposes to eliminate standardization and creates more benefit flexibility. The rule also allows for multi-year catastrophic coverage and expands the coverage to more people including those over 30. And Trump also wants to get back to what we think of as non-traditional coverage. There will be fallout in the Exchanges for sure, but it is hard to argue some experimentation is not need given huge premiums spikes and the underinsured problem. Younger generations are also looking for alternatives to traditional coverage. Some of these reforms could be implemented with real healthcare reform that tackles price, access, and primary care. Then we would be making real progress. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Value-based care has been around for a while. While it is a favorite buzzword in healthcare, some are questioning its effectiveness. Is that fair?   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses value-based care. It has been around for a while. While it is a favorite buzzword in healthcare, some are questioning its effectiveness. Is that fair?   Key Takeaways:  A recent Health Affairs Forefront blog lit a bit of a firestorm when it argued that value-based payments — and even managed care — are not going to solve healthcare affordability. They missed the fact that healthcare is in the middle of a long, messy, transformational journey — and transformation never looks impressive in the early chapters. Value-based payments are meant to move us away from the old fee-for-service system — the transactional payment model that has dominated healthcare for decades. That has driven utilization, price, and costs. And the current system does not prioritize long-term quality or outcomes. There are various value-based-care (VBC) and payment (VBP) models that have emerged, from ACOs to episodic payments to capitation to partial and global risk funds. Regions, lines of business, provider type and the size of providers all determine how penetrated VBC or VBP are. Somewhere between 35% and 45% of healthcare payments today are tied to some form of value-based model. But true risk-bearing arrangements might only account for about 20% of transactions. Critics of VBC say many pilots haven't generated dramatic savings, value-based models may be accelerating consolidation and empowering corporate intermediaries, and spending slowdowns don't appear strongly correlated with VBC adoption. But there is plenty of evidence that mature VBC models do save and drive outcomes and we just may not be there yet throughout our healthcare system.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The Trump administration released the 2027 Advance Notice for Medicare Advantage and Part D, and the near-zero rate hike sent a shockwave through the MA industry.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the release of the 2027 Advance Notice for Medicare Advantage and Part D. The near-zero rate hike sent a shockwave through the MA industry.   Key Takeaways:  In a huge shock to the industry, the Trump administration proposed a near-zero rate hike for 2027 in Medicare Advantage (MA). While the Effective Growth Rate was almost 5%, it was nearly zeroed out by two new risk adjustment reform changes. The 2027 increase stands at just 0.09% right now. That means just $700M in additional revenue in 2027 compared with $25B in 2026. Plans got no breathing room in 2027 after the new v28 risk model was phased in from 2024 to 2026 and took out 7.62% from rates. The proposed risk adjustment changes updated the new v28 model for more recent data as well as eliminated any chart review or health risk assessment submissions with diagnoses that do not have a linked medical encounter. The unlinked chart change has major impact on the biggest plans that practice very aggressive risk coding. The industry receives as much as $7.5B annually now for unlinked charts. Last year, the effective growth rate grew by almost 3% from the Advance Notice to the Final Announcement. That could happen again and move the rate for 2027 to just below 3%. This is still far below the 5% from 2026. A Stars restructuring that will reduce ratings and quality bonuses in the future compounds the overall gloomy financial picture. The MA recovery will be complicated by the rate announcement and more benefit, product, and geographic contractions are likely in 2027. The era of free-wheeling rates and risk adjustment is over. Plans need to focus on clinical management, quality, and cost control. One silver lining: overpayments are coming down and it is tantamount that the industry ensures Congress knows this before lawmakers push through more reforms.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The 2024 National Healthcare Expenditure Data are out and there are huge warning signs for the country. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the releases of the 2024 National Healthcare Expenditure Data. There are huge warning signs for the country. Key Takeaways:  The 2024 National Healthcare Expenditure Data were finally released after a delay due to the government shutdown. In 2024, healthcare spending in the United States rose to $5.279 trillion, a $353.3 billion or 7.2% increase. Healthcare expenditures as a percentage of gross domestic product went from 17.7% in 2023 to 18% in 2024. This was largely driven by heightened utilization (use and intensity) and a shift in the types of services consumed (4.7%) and less so for actual inflation (2.5%). Hospital care was 31% of expenditures, physician and clinical services 21%, and prescription drugs 9%. The insured share of the population was 91.8% in 2024— down slightly from an historic high of 92.5% in 2023. Private Health Insurance was 31% of spending and reached $1.6 trillion in 2024, an 8.8% increase. Medicare was 21% of spending and reached $1.1 trillion in 2024, a 7.8% increase. Medicaid was 18% of spending, increasing 6.6% to $931.7 billion in 2024. Out-of-pocket costs were 11% of total expenditures and increased 5.9% to $556.6 billion. The typical working family in the U.S. spent $3,960 on healthcare-related costs in 2024, including premiums and out-of-pocket expenses. The robust growth shows the challenges ahead for healthcare. It was the second consecutive year costs trended up more than 7%.  The ongoing growth in NHED is clearly not sustainable. Without major reform, we are faced with a number of compounding problems – economic stagnation, more Americans will become uninsured and underinsured, and healthcare will become more and more unaffordable. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

Donald Trump's new healthcare plan falls short and does not truly make things affordable. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses Donald Trump's new healthcare plan. It falls short and does not truly make things affordable. Key Takeaways:  Donald Trump announced his "Great Healthcare Plan" on TikTok recently. It is at best a skeletal framework and would need Congress to pass legislation. The two main tenets include drug price reform and expansion of Health Savings Accounts (HSAs) in lieu of some or all of the current Exchange subsidies. It is unclear just how far-reaching the HSA expansion would be. Other proposals include transparency at health plans. The proposal would need congressional action and Trump's views dovetail with many in Congress advocated by the GOP. Conservative House Republicans propose to pass a second budget reconciliation bill that includes replacing Exchange subsidies with HSAs, pharmacy benefits manager (PBM) reform, and more. The Senate framework for the Exchange subsidy compromise also includes HSA expansion, ICHRA expansion, and more alternative coverage expansion. Other Senate bills would replace Exchange subsidies in whole or part or offer options to use HSAs instead. The HSA expansions could undermine the Exchange market and lead to a rate death spiral as risk rises. In general, Trump's proposals do not get to the root cause of unaffordability – prices in the system. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

We dive deep on GLP-1 coverage and drug price reform models. President Trump certainly deserves credit for the major accomplishments.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc dives deep on GLP-1 coverage and drug price reform models. President Trump certainly deserves credit for the major accomplishments.   Key Takeaways:  We dive deep on GLP-1 coverage and drug price reform models. President Trump certainly deserves credit for the major accomplishments. The president has been proposing seismic reforms for drug pricing, including direct talks with brand drug makers. Over a dozen drug makers offered price concessions, including makers of GLP-1 weight-loss drugs. A new Medicare and Medicaid model would reduce costs for GLP-1 weight-loss drugs and expand coverage to help those with obesity alone and no other underlying disease states. Cost-sharing would be no more than $50 per month in Medicare. The models start in 2026 for Medicaid and 2027 for Medicare. As promised, Trump also proposed most-favored nation (MFN) drug pricing in Medicaid and Medicare. The Medicaid model is called GENEROUS and would set MFN pricing on all Medicaid drugs for participating drug makers. The MFN price in Medicaid would be the second-lowest price in a set of eight developed world countries. The Medicare models are called GLOBE for Part B drugs and GUARD for Part D drugs. A subset of B and D drugs would be covered, and the models are mandatory for drug makers. About 25% of beneficiaries with B or D drug costs would be in each model. The MFN price in Medicare B and D is based on 19 developed-world countries and would be either the lowest international price from commercially available data sources or the average international price as reported by drug makers. A big debate has emerged on MFN pricing and the impact on innovation. Some advocate for prospective MFN on new drugs only, while others want retrospective MFN, applying it to existing drugs as well.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

There is little question that affordability will dominate the 2026 midterms and that is most true on healthcare. Learn more on the issue as well as on the prospects for a possible Exchange subsidy compromise. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses that affordability will dominate the 2026 midterms and that is most true on healthcare. He also discusses the prospects for a possible Exchange subsidy compromise. Key Takeaways:  Affordability will dominate the 2026 midterms and that is most true on healthcare. We have seen huge price and inflation trends in healthcare since coming out of the COVID pandemic and there is little sign that the aggressive trends will subside anytime soon. Family coverage now costs on average almost $27,000, with employees paying almost $7,000 of the upfront cost. Medicare costs are rising by 10%. The One Big Beautiful Bill Act (OBBBA) will cause millions to lose coverage in Medicaid and the Exchanges Premiums will surge in the Exchanges if the enhanced subsidies expire. The GOP hopes it can pin unaffordability on the ACA of 2010, but it remains a popular law. It will also try to pass other conservative healthcare reforms. But Democrats will point to the OBBBA as a major culprit for unaffordability and win the day. There is at best a 50-50 shot a compromise on enhanced Exchange subsidies passes in January, but there are barriers including opposition from conservatives. A possible grand bargain could include a shorter extension, some reforms of existing enhancements, and some conservative healthcare reforms. If lawmakers really wanted to tackle affordability, they would implement site neutral payments, set prices for medical services and drugs, tackle the primary care crisis, and more. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A major study shows that investing in primary care and managing disease states could reap huge savings and improve outcomes. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses a major study showing investments in primary care and managing disease states could reap huge savings and improve outcomes. Key Takeaways:  America spends the most on healthcare but has the worst outcomes. One reason is the lack of focus on primary care and management of disease states. America has huge inpatient costs due to admissions for uncontrolled conditions.  Forty-three percent of patients with diabetes and heart disease are not treated at all with evidence-based treatments and only 20% are treated adequately based on evidence. Wakey Consulting finds that annual wellness visits (AWVs) can demonstrably help control costs among Medicare beneficiaries. Wakley found that AWVs are considerably underutilized. About 45% of beneficiaries had just one or no such visits during the study period. But showing how such visits can reduce costs and improve outcomes, Medicare beneficiaries who had 4 to 6 visits during the study period had lower inpatient and emergency department spending. Those who received AWVs had an average $885 reduction in total costs per beneficiary per year. The $885 is almost 6% of Parts A and B spending in 2024. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

As always at the end of the year, I recap healthcare happenings and tell you my predictions for the new year – just don't hold me to them! About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the healthcare happenings in 2025 and makes some predictions for 2026. Key Takeaways:  It was a busy year in healthcare with insurer woes, a new president, and a decidedly different healthcare policy approach. The One Big Beautiful Bill dominated a lot of the news in the first half of 2025. It led to a massive tax cut package that cut healthcare in Medicaid and the Exchanges by $1 trillion over ten years. The government shutdown for a record 43 days over whether Exchange subsidy enhancements would be extended. So far, they were not. President Trump laid out an aggressive drug price reform agenda and so far has gained a lot of concessions and is pressing on with most-favored-nation price reform. There was an insurer meltdown that led to executive changes and massive realignment and contraction in the industry, especially in Medicare Advantage (MA). A PwC report said that there would be huge digital investments and a move to personalized care. $1 trillion would be spent annually on the tech transformation in healthcare by the mid-2030s. My 2025 prediction report card was pretty good. I correctly forecast deep cuts in healthcare, a healthcare shakeup by Trump, drug price reform, and the expiration of subsidies at year's end. My 2026 predictions include a striking of drug tariffs by courts, another GOP healthcare bill, Congress and CMS pushing many MA reforms, and Democrats taking back the House in midterms. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Each year I help people make their open enrollment decisions. These stories tell us just how unaffordable healthcare is in America.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the counseling he does to help people make their open enrollment decisions. These stories tell us just how unaffordable healthcare is in America.   Key Takeaways:  Each year I help many people make their open enrollment decisions. One person just got a subsidy due to a quirk in the law in states that did not expand Medicaid under the Affordable Care Act. But the stats show that a reasonable Silver plan still costs over $800 per month for age 30. One person's income will now mean he does not get any subsidy if the enhanced premium subsidies expire. He will pay about $20,000 in premiums for a family of two before and deductibles or cost-sharing. I helped two elderly people find the right Part D coverage even with the major financial challenges in the program. One person is 63 and desperately awaiting Medicare coverage. She relies on the Exchanges and given her income and age can only afford a Bronze plan with limited upfront coverage right now. Statistics in the employer, Exchange, and Medicare worlds all show rising unaffordability of healthcare. It is time to reexamine minimum essential benefits, provider pricing in healthcare, and how we think about comprehensive coverage. Rich benefits ae useless if you cannot afford the policy or use the benefits.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

Given all going on in healthcare, it is time to contemplate real reform.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the fact that it is time to contemplate real reform given all going on in healthcare.   Key Takeaways:  Zeke Emmanuel, one of the key authors of the Affordable Care Act (ACA), had an interesting opinion piece in The Washington Post on December 2. It suggests many of the reforms I spelled out in my book, The Healthcare Labyrinth. He calls out price as a huge concern for healthcare affordability and suggests site neutral payments and price caps. There have been some promising developments this year, including a small step toward site neutrality and drug price reforms. Price, costs, and premiums have been increasing dramatically (6% to 9%, if not more) annually, putting coverage out of reach. That may mean we have to rethink comprehensive coverage. Some coverage may be better than no coverage at all or the inability to use your coverage. There are some innovative ideas evolving that might encourage upfront primary care, including direct primary care tied to health savings accounts. A new traditional Medicare pilot would also target controlling chronic conditions. It is a good idea. Trump is now joining the crowds attacking health plans, arguing insurers make too much in profit. The last five years proves the declaration to be false.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

CMS issued some major regulatory proposals in its draft 2026 Medicare Advantage and Part D rule.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the recently released draft 2026 Medicare Advantage (MA) and Part D rule. Some major regulatory changes are in store for plans.   Key Takeaways:  The proposed CMS MA and Part D rule for 2027 was issued timely despite the government shutdown. It includes some significant changes. The Star changes were the biggest, including repeal of the Excellent Health Outcomes for All equity reward and the sunset of operational measures. CMS' focus in the balance of the rule is reducing regulatory burden and streamlining regulations. Various utilization management health equity requirements codified by the Biden administration are proposed for repeal. Four RFIs were issued, including seeking input on reforming the risk adjustment and Stars programs due to perceived overpayments as well as poor quality outcomes. As with the rule, new program audit guidance from CMS streamlines the audit process and follow-up.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

CMS wants a much tougher MA Star ratings program and that could challenge plans and mean billions in lost revenue.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the fact that CMS wants a much tougher Star ratings program in Medicare Advantage and that could challenge plans and mean billions in lost revenue.   Key Takeaways:  Medicare Advantage Star ratings are in the doldrums. Little progress was seen in Star Year 2026 results. Now, CMS says it wants to make the program even tougher. CMS is getting rid of "layup" measures -- mostly operational metrics – in favor of concentrating on more complex clinical measures to drive quality outcomes. This is not a total surprise as the Biden administration telegraphed this before leaving. The change would shift emphasis to drug, health outcome, and improvement measures. CMS also wants to eliminate the Excellent Health Outcomes for All reward slated to go into effect for SY 2027 because it dislikes anything health equity. The proposal to eliminate the long-planned reward could be legally dubious. Getting tougher and refocusing is not unreasonable, but it could mean billions in revenue is lost by MA plans. At least 25% of contracts could lose at least half a Star rating. Complicating the Stars picture is MA plans' focus on dual eligibles and Special Needs Plans. These individuals tend to perform much worse on clinical measures. To succeed, plans will need to invest more in Stars. The pivot to true healthcare outcome measures will require quicker and better data collection and analysis, better tracking and forecasting, ongoing strategy refinement, and novel tech-based interventions to close gaps on everyone.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A new study looking at what UnitedHealthcare pays its sister providers could bring scrutiny of vertical integration in healthcare.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses a new study looking at what UnitedHealthcare pays its sister providers. This could bring scrutiny by CMS and Congress of vertical integration in healthcare.   Key Takeaways:  Vertical integration in healthcare is all the craze. Large healthcare entities are especially plotting vertical integration strategies to grow. Vertical integration leads to intercompany transactions among sister companies within the controlling entity. These agreements occur between plans, PBMs, providers, service entities, and pharmacies. Between 10% and 20% of Big Plan insurer spending is with sister companies. These agreements are shown to have higher than arm's length or market reimbursement. A recent study shows that UnitedHealthcare pays its sister company providers well more than other providers. While vertical integration may not be a bad thing in some cases, insurers need to reform how they approach such agreements so as not to disadvantage consumers and businesses. Congress and CMS, too, need to look at consolidation overall and these inside deals.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The drug price reform arena is active, with a major announcement on drug rebate reform and GLP-1 weight-loss drug price reductions.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the fact that drug price reform arena is active, with a major announcement on rebate reform and GLP-1 weight-loss drug price reductions.   Key Takeaways:  Cigna's Express Scripts PBM announced it will begin introducing net pricing and migrate in part away from drug rebates. Consumers will get the benefit of the lowest price at drug counters. The new model will save members an average of 30% each month on brand drugs. It will also enhance how it pays pharmacies. Cigna says it will deploy the strategy for its plan offerings and offer the net price options as the default to all employer groups and clients. It is a step forward but is not real reform – it does not eliminate rebates, is a hybrid approach, and many plans and employer groups may still maintain the rebate structure. PBMs should not write the reform script, and the government should eliminate rebates entirely. President Trump announced major concessions of GLP-1 weight-loss drugs for self-pay and Medicare, including a $50 co-pay cap. There is much confusion surrounding when Medicare cost-sharing reductions go into force, whether those with obesity alone will truly benefit, and Medicare cost impacts. The concessions do not impact Medicare drug price negotiations, and the president should ensure broad drug price reform across lines of business.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Donald Trump and the GOP may want another pass at repealing and replacing Obamacare. But they have never had a real plan.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses that Donald Trump and the GOP may want another pass at repealing and replacing Obamacare. But they have never had a real plan.   Key Takeaways:  Just as midterm elections begin to kick into high gear, President Trump and other GOP officials are saying the want to take another pass at repealing and replacing the Affordable Care Act (ACA) or Obamacare. CMS Administrator Dr. Mehmet Oz says the president has a hidden plan. Trump himself urged the parties to get together to pass reform because Obamacare is so bad. He then lambasted Democrats over the law in a social media post. The GOP does not appear to have a plan to extend expiring the Exchange's enhanced premium subsidies to avert huge premium surges. The GOP is said to be talking about an extension with some conservative-minded reforms. But we have never seen a true plan from the GOP that would not lead to a huge surge in the unsured rate – not in 2017, not during the 2024 election, not during the debate on the One Big Beautiful Bill, or now. Americans deserve a measured subsidy extension with some reforms. The GOP should put up a realistic plan for coverage or shut up about it. The periodic pronouncements are unsettling to the tens of millions of Americans who rely on the ACA for coverage. Ripping apart the ACA as we know it now with nothing truly comprehensive to replace it with would mean millions losing coverage.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A judge has tossed the entire Risk Adjustment Data Validation rule, throwing CMS' plans to audit MA insurers for overcoding into great doubt.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses a court decision to toss the entire Risk Adjustment Data Validation rule in Medicare Advantage. This throws CMS' plans to audit MA insurers for overcoding into great doubt.   Key Takeaways:  A federal court has vacated the 2023 Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit rule finalized during the Biden years. The court nullified the entire rule not just portions of it. The decision was not unexpected. The Biden administration included so many far-fetched and indefensible provisions. At the same time, it is a bit of a shocker as it throws the Trump administration's plans for a 100% RADV audit commitment into great flux. Humana challenged the rule, arguing the agency did not follow the regulatory act and various parts were unlawful, including extrapolation, retroactivity, and the omission of a factor that took into account differences between the traditional program and MA. The court in the RADV case found that CMS did not follow the procedural requirements and vacated the rule entirely without ruling on specific arguments from Humana. The government wanted to conduct 100% audits on each contract each year given major overpayments to MA plans in part due to risk adjustment overcoding. But studies seem to prove that a small subset of larger plans have the bad practices and gain disproportionate revenue from overcoding. Audits will be hard to conduct with no rule, but CMS will come back to try to implement a new one. Further, CMS and Congress could see overpayment reform that could be far more injurious than the audits for most plans. Plans should undertake a number of potential actions, including reforming their risk adjustment coding practices and endorsing reasonable reforms.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

Quiet Discussions On Capitol Hill On An Enhanced Subsidy Extension   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the quiet talks on Capitol Hill on an enhanced subsidy extension.   Key Takeaways:  Quiet talks are occurring on Capitol Hill on the status of the enhanced Exchange subsidies. During the COVID pandemic, the base premium subsidies were enhanced and will expire at the end of this year. The enhanced subsidies significantly reduced expected premiums against the permanent law, especially at lower incomes. At the same time, it removed the 400% poverty level cap on subsidies. Negotiations are ongoing between the White House and moderate Republicans and Democrats in Congress. While most Republicans oppose any extension, GOP leaders may have to bow to moderates' and swing district holders' demands. Democrats say they will not vote to reopen government unless the subsidy issue is addressed. Without an extension, consumers would see an average increase of 114% from an average of $888 in 2025 to $1,904 in 2026. Millions could lose coverage due to affordability issues. Individuals making $18,000 would pay $378 more a year, with individuals making $55,000 paying $1,469 more a year. A family of four making $40,000 would pay $840 more a year, with a family of four making $110,000 paying $3,201 more. Older, middle- to high-income adults are expected to face the largest dollar increases in premiums. Hikes will also vary by markets in each state. On the table to get to a compromise are a short-term extension, an income cap on subsidies, minimum premiums for everyone, and allowing the enhancements only for existing enrollees.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

We dive deep into the 2026 Medicare Advantage Star Ratings Results About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc dives deep into the 2026 Medicare Advantage Star Ratings results. Key Takeaways:  Star ratings in Medicare Advantage peaked in 2022, and in the next three years we saw steep declines in results. 2026 results are mixed. We saw ratings stabilize but results are still among the lowest in many years. Some measure performance is improving: Some cut points, average measure values, and average measure ratings seem to show plans doing better over the past few years coming out of the COVID pandemic.  Contracts 4 Star or greater are stable: In SY 2025, about 40% of all rated contracts were 4 Star or greater. For SY 2026, about the same 40% are in contracts with 4 Star or greater. Enrollment in 4 Star or greater is stable: In SY 2025, about 62% of all MA enrollment was projected to be in contracts with 4 Stars or more. That grew to 64% as of late. For SY 2026, it appears about 64% of all MA enrollment will be in contracts with 4 Stars or more. Average Star ratings are slightly higher: Both the contract average rating and enrollment weighted average rating improved. The contract average rating went from 3.63 in 2025 to 3.65 in 2026. The enrollment weighted average rating went from 3.92 in 2025 to 3.98 in 2026. The 2025 enrollment-weighted average has grown to 3.96.  The continuation of poor performance is driven by the inconsistent performance of big plans, which are about three-quarters of all enrollment. United, Elevance, Kaiser, and Centene saw positive results. Humana, Aetna, and HCSC went down. Performance across big plans is still very different. On the Insurtech side, Devoted and Alignment continued to do well. Clover Health, though, saw its largest contract dip below 4 Star. That contract has 97% of its members. Star Year 2026 had 45 MA-PD measures — 33 Part C and 12 Part D. Three measures were new and did not have ratings in SY 2025. In terms of Part C measures from 2025 to 2026: 13 measures increased, 6 stayed the same, and 11 dropped. In terms of Part D measures: 6 measures increased, 2 stayed the same, and 4 dropped. There are significant challenges moving forward with tougher measure specifications, new measures, and the new Excellent Health Outcomes For All (was the Health Equity Index). Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Are President Trump and his healthcare policy advisors getting hoodwinked by Big Pharma on drug price reform? About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode:   On this episode, Marc discusses drug price reform and asks if President Trump and his healthcare policy advisors are getting hoodwinked by Big Pharma.   Key Takeaways:  Are President Trump and his healthcare policy advisors getting hoodwinked by Big Pharma on drug price reform? President Trump has come out swinging in Trump 47 on drug price reform and I applaud that. He has shown a good understanding of the drug price system and what needs to be done to reform it. He is using all sorts of ways to cajole and even extort concessions from Big Pharma. It is admirable. He has proposed the most favored nation form of drug pricing, where America would adopt the lowest price on each brand drug anywhere in the developed world. But Trump could back off aggressive reforms based on proposed concession deals from brand drug companies. These deals do not amount to fundamental drug price reform, but window-dressing and efforts by Big Pharma at self-preservation. The targeted reforms do not fundamentally change price for the vast majority of consumers or the system as a whole. Trump should stick to his game plan and truly reform drug price. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Special Needs Plans are growing explosively in Medicare Advantage, but understanding the operational risks is key.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the explosive growth of Special Needs Plans in Medicare Advantage. Health plans need to understand the operational risks as well as the opportunities.   Key Takeaways:  Plans have been investing heavily in SNPs for several years now and this occurred even with the financial woes many saw in 2024 that led to a massive retrenchment in terms of geographies, products, and benefits in 2025. While individual MA plan offerings declined by 6.54% in 2025, SNP offerings increased 8.5% in 2025. From January 2020 to September 2025, SNPs grew from 3.687M to 7.909M, a growth of 4.222M or 114.51%. About half of the growth noted above has come since January 2023. Dual-Eligible or D-SNPs have dominated the numbers, capturing 3.351 of the 4.222 growth, or 79% of all growth. They grew 118% in the timeframe. Chronic Care or C-SNPs grew the most from a percentage standpoint in the timeframe, growing by 1M or 271%. Plans are investing due to the CMS Medicare-Medicaid integration strategy, synergies plans see between the two lines of business, and the potential for greater revenue and margin with SNPs. But there are risks as well, including the current rate and risk adjustment environment, immature clinical oversight, greater integration, challenges with Star performance for dual eligibles, and the robust audit environment. Program audits look at both SNP regulations and a plan's Model of Care compliance as well. Audits no longer limit their focus to health risk assessments and care plan issuance, but go deep into clinical practices, engagement of members with care teams, and how identified problems have been addressed. CMS sees the increased use of technology as a dynamic and cost-effective way to identify problems and risks as well as undertake intervention strategies.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

We are covering two topics in this edition – healthcare price disparity between the U.S. and other developed countries as well as the current health plan landscape.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc covers two topics – healthcare price disparity between the U.S. and other developed countries as well as the current health plan landscape.   Key Takeaways:  Part 1: Price Disparity The Peterson-KFF Health System tracker looked at price and utilization in the U.S. and 11 other developed nations. It finds that the U.S. has higher prices for many healthcare services and that we spend more than any other large, developed country on healthcare. However, utilization of many services is lower than in many comparable countries. The study says this has been the case for some time. Costs ultimately are driven by price and utilization. In this case, the study says price in America is the big culprit for higher costs than in other nations. The U.S. spends nearly twice as much on healthcare per person as the average of peer nations. Part 2: Health Plan Landscape There is an ongoing financial meltdown at health plans and the One Big Beautiful Bill will not help matters in terms of recovery. There are a number of different unsettling things on Medicare Advantage, including poor Star performance, risk adjustment revenue scrutiny, and prior authorization limits. Expect more benefit and other contraction in MA in 2026. Plans will need to pivot to real-time data analysis and engagement to reduce costs due to restrictions on prior authorization across all business lines. Plans will also look at agentic AI to help reduce administrative costs and enhance member and provider outreach. Ultimately, we need healthcare reform focusing on price reform, wellness and care management, and affordable access.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

While the No Surprises Act has saved Americans from huge surprise bills, the law is fundamentally flawed and needs to be reformed.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode:  On this episode, Marc discusses the No Surprises Act. It has saved Americans from huge surprise bills, but the law is fundamentally flawed and needs to be reformed.   Key Takeaways:  The No Surprises Act has saved millions of Americans from huge surprise bills. The Blue Cross Blue Shield Association projected in early 2024 that the NSA averted 10 million surprise bills in the first nine months of 2023 alone. Another study finds that there was a $567 decrease in out-of-pocket (OOP) spending related to surprise billing for people living in states that did not have protections before the national law. The study finds that the NSA appears to be generating more savings to Americans than other coverage measures or cost reductions and protections. But the baseball-style arbitration process in the law is heavily stacked against health plans and favors providers.  In baseball-style arbitration, an arbiter decides between one or the other last best offers from the sides and cannot craft a middle ground. A new study by Georgetown University researchers and published in Health Affairs, show that providers have won 85% of disputes since the fourth quarter of 2023. In these cases, the median payments were three to four times higher than average median in-network rates. There has been over $5 billion in total costs through the end of 2024 due to the law. Additional payments were about $2.24 billion, with additional administrative costs and fees totaling $2.78 billion. Annually, this totals $2 to $2.5 billion a year in increased costs. The study also finds that the majority of the disputes are filed by a small number of providers that are backed by private equity firms. At least three major insurers have now sued various providers over their abuse of the dispute resolution process. The bill has and will continue to increase costs in the healthcare marketplace. Reform is absolutely needed.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Notwithstanding my opposition to most of what is in the One Big Beautiful Bill, not everything in it was bad policy. After all, we do need accountability in government programs.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses that not every healthcare reduction in the One Big Beautiful Bill was unreasonable. We do need accountability in government programs.   Key Takeaways:  I have taken the position that most of the reductions to healthcare in the One Big Beautiful Bill Act (OBBBA) were simply bad policy. As a former state budget director and management secretary, I do believe in accountability of government healthcare programs. Areas I see in the OBBBA that promote accountability include certain provider tax reforms, some state directed payment changes, and verification of eligibility reforms. Democrats support universal access but have rarely asked if their policies do or do not promote accountability, real reform, efficiency in the system, and creating cost-effective coverage options. Their unfettered policy positions ignite massive spending growth to the detriment of long-term stability of the system as a whole. Case Study 1: Democrats passed a series of cost-sharing reductions on Part D, largely to score political points in the 2024 election. The changes have destabilized the standalone Part D program, leading to premium and cost-sharing hikes, benefit reductions, and less choice and access. Case Study 2: Democrats also fostered huge opportunities for Exchange enrollment fraud because enhanced premium subsidies became so generous and eligibility and enrollment so liberal. This led to phantom enrollees. The number of Exchange individual market enrollees with no medical claims more than tripled from 2021 to 2024. The percentage of individual market enrollees with no claims jumped from fewer than 20 percent in 2021 to 35 percent in 2024—an increase of nearly 80 percent in three years. Democrats ignore such issues in favor of expansive and unaccountable healthcare. The GOP has become so suspicious of healthcare expansion due to the lack of accountability. Unless we solve this issue, healthcare reform in Congress will be a long way off.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A combination of events come together to create a worrisome erosion of coverage in the next decade, driving up both the uninsured and underinsured counts.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses a worrisome erosion of coverage in the next decade, driving up both the uninsured and underinsured counts.   Key Takeaways:  Two forces are coming together to further erode coverage in America. They are surging utilization and the OBBBA. Some of the surging utilization can be explained – a return to normal post pandemic utilization, increased expensive drug introductions, aging and more. But some of it cannot. While healthcare actuaries anticipate a slowing of annual healthcare growth in a few years, I think we could be in a new era of even more robust annual growth. When utilization spikes, as much as employers try to protect employees, more costs are foisted upon them or coverage evaporates. While the GOP says no one will lose coverage unless it is fraudulent or they want to be tossed, we know this is far from the truth. With the expiration of Exchange premium enhancements, 15 million will lose coverage in Medicaid and the Exchanges. We have seen very low uninsured rates due to coverage expansion. That will increase dramatically through 2034. The bigger problem could be the rise in the underinsured rate. Surging utilization, costs, and the fallout from the OBBBA will mean more and more fall into the ranks of the underinsured. Latest statistics say about 8% to 9% of adults are uninsured, 12% had a gap in coverage over the past year, and 23% were underinsured (they had coverage for a full year that didn't provide them with affordable access.) We are in a crisis. It is clear that the uninsured and underinsured rates will rise because of misguided policies and the lack of true healthcare reform.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

Given the major MA retrenchment in 2025, many are asking what will happen to offerings, geographies, and growth in 2026. I tell you.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses what will happen to offerings, geographies, and growth in Medicare Advantage in 2026.   Key Takeaways:  Since January 2020, MA enrollment has grown from 23.93 million to 35.44 in July 2025, a growth of 11.51 million. From January 2020 to January 2024, average growth was 10%, ranging from 6% to 11%. Growth from January 2024 to February 2025 did come down considerably to 4.4%.  Since February, MA continues to grow at a healthy pace overall. Between February and July, almost 500,000 lives were added to the MA rolls. We are likely in store for a rate of growth from 2025 to 2026 that is similar to 2024 to 2025. It is clear that the major retrenchment by MA plans in 2025 impacted overall growth. But a great value proposition compared with the traditional program sustains growth. 2025 brought a reduction in some added benefits, a major contraction of the Preferred Provider Organization (PPO) product, and geographic contraction. While many plans pulled back, national MA plans struggled the most in terms of benefit cuts, contraction, and growth. While Individual MA plan offerings declined by 6.54% in 2025, SNP offerings increased 8.5% in 2025. And SNPs have grown considerably since January 2024. In the end, robust competition remained, $0 premiums prevailed, and most enrollees could find very favorable plans. Some analysts are speculating that contraction of benefits, products, and geographies could be robust again this year. But will it be as big as 2025? I do not expect the enrollee impacts to reach what we saw in 2025. But based on recent announcements from United and Aetna, we can say the contraction in benefits, products, and footprint could again be sizeable in 2026.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

While outside forces contributed, health plans, especially the big ones, can blame their own mismanagement on the insurer meltdown.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the financial crisis of health plans. While outside forces contributed, health plans, especially the big ones, can blame their own mismanagement on the insurer meltdown.   Key Takeaways:  Outside forces contributing to the meltdown were high utilization and government actions that reduced rates and revenue and limited cost-savings opportunities. But health plans generally and the big plans specifically missed the financial mark. Big plans were over-zealous and had a severe lack of financial discipline. In Medicare Advantage, health plans ignored lower rates, lower Star performance, risk adjustment reform demands, and prior authorization limits. In Medicaid, plans grew too much, ushered on by what were temporary rules expanding growth and reimbursement. In the Exchanges, insurers did not plan for the eventual phaseout of enhanced premium subsidies. In the employer and commercial world, health plans did not respond to demands for cost-savings and greater transparency by insurers. The current trends, including the budget reconciliation bill, likely would have meant further retrenchment in all lines of business. But it is equally true that the lack of financial discipline by most of these plans in the last several years complicates their recovery.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Direct Primary Care and other reforms could save employer coverage.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses the Direct Primary Care model and other potential reforms to employer coverage.   Key Takeaways:  Direct Primary Care was boosted in the recent budget reconciliation bill. DPC is a healthcare model (not insurance) where patients pay a recurring, fixed fee directly to a primary care physician for access to a defined set of services. Opponents see DPC as limited and nowhere near comprehensive coverage, but it can be teamed with a high-deductible health plan (HDHP). Many employees struggle to afford employer offerings and a DPC with an HDHP could create a cost-effective yet robust option. Under the budget bill, DPC account holders can utilize their HSAs to pay for DPC service arrangement fees. DPCs will grow both individually but also as an employer offering. Smaller employers may look to DPCs with HSAs and HDHPs to lower their costs as well as those of employees. Employer coverage costs have been growing profoundly the past several years. Employers are increasingly frustrated with health plans and PBMs as relationships are not transparent. Plans and PBMs operate within black boxes. A new bill could bring unprecedented transparency to employer coverage by mandating sweeping reporting and data sharing with employer groups. The bill would promote competition and empower employers during negotiations.   Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A recent House hearing on Medicare Advantage shows what is in store for plans. It may not be good. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses a recent House hearing on Medicare Advantage and what may be in store for plans. It may not be good. Key Takeaways:  Capitol Hill has become far more active on MA issues, although major reform legislation has yet to pass. Democrats spoke of their usual gripes – overpayments MA and the need to augment the traditional Medicare fee-for-service (FFS) program. Republicans, who generally supported the program, were on board for many of the same reforms Democrats proposed. Lawmakers want action on MA overpayments. Lawmakers complained that supplemental benefits are not truly being spent on enrollee care. Lawmakers and MA executives pitched the idea of multi-year enrollment to stop marketing abuse, high expenses, and to promote care management. PA and claims denials were cited as the biggest concern by providers. Some argued that value-based care (VBC) payment mandates could promote the recovery of independent primary care practices. Some lawmakers feel the largest plans are abusing the system and giving the program a bad name. A number of bills have been filed to respond to these concerns. MA actually saves both Medicare and consumers quite broadly, and quality is markedly better. It is ironic that CMS now wants to introduce PA in the traditional Medicare program, arguing FFS is wasteful. Show Links: AHIP blog Better Medicare Alliance website Better Medicare Alliance statement Elevance Health Public Policy Institute Study Connect with Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

CMS' Medicare Advantage (MA) program audits are getting tougher and more detailed every year.   About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode: On this episode, Marc discusses Medicare Advantage compliance. CMS' program audits are getting tougher and more detailed every year.   Key Takeaways:  Overall, CMS' program audit protocols are fair and reasonable. They hold plans accountable for the delivery of care to Medicare beneficiaries. There are four core audit protocols and a fifth for Special Needs Plans. The 2023 and 2024 program audit report shows MA audits are getting tougher and more detailed. Compliance Program Effectiveness is closely being scrutinized due to concerns about oversight of delegated vendors. Formulary Administration is also an active area due to concerns on correct prior auth edits, claims configuration, cost-sharing, and transition fills. Scrutiny of medical service and drug authorizations and appeals remain very detailed, with clinicians digging deep into cases and determination of medical necessity. On Special Needs Plans, CMS is always concerned about health risk assessments but is now going beyond that to determining if care plans are addressing all of the identified needs of individuals. CMS says plans are implementing and carrying out the new utilization management rules, but scrutiny should increase in the future. Financial audits are also increasingly rigorous and focused on no beneficiary harm. Record civil monetary penalties were levied in 2024.   Connect with Marc: Marc on LinkedIn Marc on Twitter THL Podcast   Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

While justified, there is some question about whether the new RADV audits will be fair to MA plans. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the new 100% RADV audits. While justified, there is some question about whether the new RADV audits will be fair to MA plans. Key Takeaways:  CMS announced it will audit all Medicare Advantage (MA) contracts for each payment year. How it will ramp up staff and technology to hit the aggressive announcement is another question. Opponents of MA call out dubious numbers on the magnitude of overpayments, but there is some risk adjustment abuse by a small number of plans that disproportionately benefit. About half of contracts have been noticed for RADV audits in payment year 2019. The 2023 RADV rule is controversial and being challenged by plans. The new audit process adds to the controversy. CMS will use a suspect approach and target diagnosis codes for HCC risk adjustment clusters most at risk of abuse. Fewer records can now be submitted, which ups the ante on accuracy, timeliness, and completeness during the submission period. The suspect sample audit approach and extrapolation of penalties should be a major concern. Will the industry end up worse off with the suspect approach than a more comprehensive one? Does the government now conduct RADV audits in an Elon Musk, "DOGE-like" approach, storm-trooping for maximum recoupment to hit lower spending targets rather than a fair and transparent process rooted in real program integrity? Other reforms could also be implemented. Connect with Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The Big Beautiful Bill buried some other important healthcare developments. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the other major healthcare developments that got buried by the One Big Beautiful Bill the past two months. Key Takeaways:  The Big Beautiful Bill buried some other important healthcare developments. Health plans committed to significant prior authorization reforms. CMS will not propose further reforms right now as it monitors health plan implementation. Plans will reduce the number of PAs required and pursue electronic processing, some in real time. Numerous state and federal restrictions are already in place and the new commitments will hurt plans' ability to control medical expense. CMS Administrator Dr. Mehmet Oz wants pharmacy benefits managers (PBMs) to end the complicated system of drug rebates, or the government will step in to change it. Oz also hinted that the Trump administration could issue a rule that is focused on drug price transparency. The Supreme Court ruled 6-3 in favor of allowing preventive services to continue under the Affordable Care Act (ACA). Last, CMS announced that it will have a 100% Risk Adjustment Data Validation audit for every payment year for every contract. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The one big beautiful bill has passed. Listen in to learn about how it happened and the impact of healthcare reductions. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the one big beautiful bill passing. Listen in to learn about how it happened and the impact of healthcare reductions. Key Takeaways:  The one big beautiful budget reconciliation bill passed on tight votes in each chamber of Congress. Trump and GOP leaders are given a great deal of credit for getting the controversial bill through and satisfying both moderates and conservatives in the caucus. The GOP tried to be very stealthy in terms of cuts, but major impacts will occur. Cuts are wide-ranging in Medicaid, the Exchanges, and even Medicare. Most notable are cuts to state provider taxes funding Medicaid, new Medicaid nationwide work requirements, and tighter eligibility in Medicaid and the Exchanges. About $1.1 trillion is cut over ten years in healthcare and almost 17 million could lose coverage when you count the expiration of the enhanced Exchange subsidies. The reductions are certain to destabilize the financial recovery of the health insurance industry. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

There are smarter healthcare cuts and sensible reforms that could be made and spare major impacts to coverage. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the budget reconciliation bill. There are smarter healthcare cuts and sensible reforms that could be made and spare major impacts to coverage. Key Takeaways:  The problem with the Republican healthcare budget reduction proposals is that these are clear and deliberate reductions to Medicaid and Exchange coverage. The GOP is being quite stealthy, but nonetheless Republican lawmakers get to the same place as more explicit coverage termination initiatives. About 16 million could lose coverage and the bill would decrease spending by $321 billion to hospitals, $81 billion to physicians and $191 billion for drugs. If the Exchange premium tax credits expire, spending would decline by an additional $262 billion. There are smarter cuts that can be made. A case can be made that provider cuts are needed to attack the high-cost and inflation problem we have in healthcare. High costs are driving premiums and creating a situation where we are priced out of healthcare. Done right, price reform brings inflation down and bends the cost curve. Over time, it could mean a real reduction in prices and costs. Done over a reasonable period of time, it would force provider reform, especially at hospitals. We need site-neutral policies. There is no reason that hospital-owned settings (outside of inpatient) should be paid more for the same services provided at independent free-standing facilities or a physician's office. Reforming the 340B drug discount program may not save major government spending, but reforms would reduce costs to employers and beneficiaries. President Trump has proposed most-favored-nation (MHN) pricing across the entire healthcare system. Several possible changes could be made to Medicare Advantage risk adjustment over time. The healthcare system could be transformed to the benefit of plans, providers, employers, and consumers. It is far superior to how each party thinks about it – the GOP's chopping at coverage and the Democrats' fixation with driving more and more coverage and benefits without a thought to efficiency. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

As bad as health plans have had it the past few years, trends seem to show the pain continuing. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the financial state of health plans. As bad as health plans have had it the past few years, trends seem to show the pain continuing. Key Takeaways: Last week we discussed how every health plan is undergoing financial strain, but Big Healthcare was especially hurting right now. Compound Annual Growth Rate EBITDA for health insurers dropped by 1.2% from 2019 to 2024. So, will all these struggles continue for the foreseeable future, despite most big health insurers seemingly beginning to dig themselves out of their financial mess? Healthcare trends as well as government actions will most assuredly mean continuing bumpy times in all lines of business. A return to pre-pandemic utilization demand and cost growth of weight-loss, specialty, and medical drugs are creating major medical expense challenges for plans. On the employer front, businesses will continue to demand greater accountability from their healthcare entities. Millions (over 8 million) could leave the Exchanges, which brings back the prospect of fewer plans, skyrocketing premiums, and higher risk. Plans have complained that Medicaid rate hikes are not keeping up with the costs from rising risk. We could see the same phenomenon as more leave the Medicaid rolls. Utilization trends and the threat of major risk adjustment revenue recoupment in Medicare Advantage could lead to greater retrenchment than expected. Plans will need to further adjust their recovery assumptions as they seek to turn around margins. Downsizing, administrative reductions, and moving from a prior authorization focus to intervention and care management are essential. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance  

The mighty big healthcare companies have fallen, in this case a victim of their own financial mismanagement and shenanigans. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses how the mighty big healthcare companies have fallen, in this case a victim of their own financial mismanagement and shenanigans. Key Takeaways: A number of external forces contributed to problems in the health insurance industry. Margins have collapsed. McKinsey finds that the EBITDA Compound Annual Growth Rate for insurers was -1.2% from 2019 to 2024. Big Healthcare has been vertically integrating a great deal over the past two decades. This has usually powered their growth and investors flocked to their sticks. But a number of large health plans have suffered major financial problems and some of the problems are impacting their non-insurance entities as well. Big Healthcare has tended to have it better financially than other insurers, but that has changed recently. Big healthcare has relied too much on suspect practices, such as risk adjustment maximization, robust prior authorization, marketing deals with brokers, and intercompany arrangements derived from vertical integration. While regional players have been hit by a financial downturn too, their greater focus on member care and relationships have put them in better shape right now. Big healthcare had bigger hits on underwriting margin and medical loss ratio (MLR) in 2024 in Medicare Advantage (MA). Regional players also did better than Big Healthcare on MA enrollment for 2025. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The GOP is not following the same overt repeal of healthcare coverage as it did in 2017, but the stealth approach still has real impact. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the budget reconciliation bill's impact on healthcare coverage. The GOP is not following the same overt repeal of healthcare coverage as it did in 2017, but the stealth approach still has real impact. Key Takeaways: In 2017, the GOP attempted an overt repeal of the Affordable Care Act (ACA) and suffered defeat in the 2018 midterms. This year, the GOP is attempting a stealth approach to Medicaid and Exchange spending reductions in the budget reconciliation bill. Still, the impact to coverage and the uninsured rate will be huge. Major Medicaid cuts include work requirements, limitations on state provider taxes to generate the state matching contribution, and various enrollment changes and restrictions. Medicaid savings are about $864 billion over ten years. The Congressional Budget Office (CBO) says about 7.8 million lose Medicaid due to the bill's provisions. Exchange coverage reductions include changes to premium tax credits for migrants, increased recoupment of premium subsidies paid out at levels that are too high from income, and increased eligibility checks. The ACA changes save about $230 billion over ten years. About 3.1 million lose coverage due to the bill's ACA provisions and some other provisions. The CBO says that about 4.2 million will exit the Exchanges and remain uninsured due to the expiration of the enhanced premium subsidies at the end of 2025. An additional approximate 900,000 would lose Exchange coverage as a result of a proposed Trump administration rule dealing with eligibility and enrollment periods. This brings the total increase in the number of uninsured to 16 million by 2034. More than a third of the ACA coverage gains would evaporate. Those losing eligibility due to the Medicaid work requirement mandate will lose coverage largely due to administrative snafus and a broken enrollment and eligibility process. Many of the eligibility proposals put unreasonable barriers to enrollment in place and are very expensive. Medicaid and the ACA are both popular programs among Americans. A good share of Republicans also supports healthcare programs. There are other ways to tackle our deficit and debt problems than to fundamentally pare back healthcare coverage, but the parties lack the political will to come together. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Managed care is entering a new conversion cycle just as Medicare Advantage plans have to pivot to thrive. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses two major trends in healthcare. Managed care is entering a new conversion cycle. And Medicare Advantage needs to pivot to thrive. Key Takeaways: We are entering a fourth conversion cycle for managed care in America. The first cycle was the birth of managed care to eliminate the transactional indemnity system. The second cycle was a managed care backlash due to the huge utilization clampdown and too little choice. The third cycle involved governments pursuing compliance, accountability, and quality reforms. The current cycle involves the advent of value-based care and digital healthcare. Medicare Advantage is facing a sea change, with governments restricting prior authorization, making quality programs more complex, and reining in liberal risk adjustment revenue practices. The above along with surging utilization and healthcare trends mean Medicare Advantage (MA) plans are in a financial crisis. MA plans need to pivot from upfront gatekeeping using utilization management to a focus on wellness, prevention, and care management. MA plans need to invest in technology and personnel to assess quality outcomes, member risk and cost trends, and member satisfaction. A mature data analytics platform deriving real-time assessment of factors as well as leveraging artificial intelligence (AI), machine learning and agentic AI engagement could be how all plans rise to the occasion and pivot their enterprises for financial success in MA. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The House has passed the budget reconciliation bill, but the Senate intends to put its mark on the bill and there are competing forces as in the House. Final passage is some time off still. About The Podcast: Millions of Americans feel confused and frustrated in their search for quality healthcare coverage. Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change. Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare. Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name. Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare. Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America. About The Episode: On this episode, Marc discusses the status of budget reconciliation. The House has passed the budget reconciliation bill, but the Senate intends to put its mark on the bill and there are competing forces as in the House. Final passage is some time off still. Key Takeaways:  The House passed the budget reconciliation bill on a very tight vote. The House vote was contentious, with both conservatives and moderates winning concessions in order to get the bill passed. To partially pay for tax cuts and extension, the bill includes $1.8 trillion in spending cuts over ten years, largely in healthcare and nutrition. The Medicaid and other healthcare cuts will mean millions lose coverage. They will have major impact on state budgets and providers. There is also a chance that sequestration rules cut Medicare spending by $500 billion over ten years. The Senate says it will make its mark on the bill and make some fairly major changes. The Senate has both moderates and conservative arguing their points as with the House. Right now, enough moderates and conservatives are off the bill to sink the House version. If too many changes occur in the Senate, that could complicate re-passage in the House. Final passage of a budget reconciliation bill will likely go into the summer. Connect with Marc Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

While his proposals seem to go against the GOP's pro-Big Pharma drug policies, populist Donald Trump is right to go all in on drug price reform.   About The Podcast:   Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.   Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.   Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.   Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.   Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.   Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.   About The Episode:   On this episode, Marc discusses how Donald Trump is going all in on drug price reform. While his proposals seem to go against the GOP's pro-Big Pharma drug policies, our populist president is right.   Key Takeaways:     Donald Trump has now issued two executive orders on drug price reform.   His first was well thought out and comprehensive. It promises to hit all areas in need of reform.   His second order seeks to establish most favored nation (MFN) pricing across all lines of business.   This could be a seminal event in drug price reform and healthcare reform overall. It is a populist move.   The Medicare drug price law was a good start but savings were small and Americans would have to wait many years for real relief.   MFN pricing would give Americans the lowest price of any other developed nation. Right now Americans pay manyfold more.   There is some doubt that Trump alone has the authority to implement this. And there are other challenges as well.   Congress likely will act on his other drug reform measures, but implementing MFN is unknown because GOP lawmakers traditionally have been lap dogs for Big Pharma.   But populist and anti-corporate-greed sentiment is taking hold in the party.   Regardless of major roadblocks, the public policy debate is critical and I think Trump can build some legislative and other consensus on the issue.    There is no reason why private healthcare in America could not leverage a national drug net price list across lines of business.    I think we can craft a middle ground that ensures reasonable access to innovator drugs and affordability.   The status quo means America will continue to have higher morbidity and mortality.    I like the no-holds-barred, mixed-martial-arts Donald Trump on drug price reform and he should press on.   Connect with Marc   Marc on LinkedIn Marc on Twitter THL Podcast   Resources   THL's Newsfeed THL's Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance