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Now is the Time to Modernize Communication in the Medicaid Program

By ABNER MASON

What do television shows 60 Minutes, Roseanne, Designing Women, and Murder, She Wrote all have in common? They were top 10 prime time shows in the 1991 – 92 season according to Nielson Media research. Obviously, what Americans want to watch has changed in 34 years. The decline in market share the major networks – ABC, CBS, and NBC – have experienced, and the dramatic growth of streaming services proves the point. It makes sense to let people watch what they want to watch on the device of their choice, and use new technologies like streaming services to access the shows they want to watch.  It would be foolish for us to insist that Americans watch only shows from the legacy networks on traditional TVs. But this is basically what we are doing now when we force Medicaid Managed Care Plans (Plans) to comply with a 1991 Federal Law when they communicate with Medicaid recipients.

Here’s the problem. Federal legislation called the Telephone Consumer Protection Act (TCPA), enacted in 1991, makes it very difficult for States and Plans to use text messaging to communicate with their members, even though texting is the primary, and preferred mode of communication for all Americans including Medicaid recipients. TCPA requires a State or Plan sending a text to have permission from the person receiving the text before the text is sent. Violations of TCPA result in significant financial penalties for each infraction, and penalties are tripled if the sender knowingly sent the text without consent.

Medicaid recipients are typically assigned to Plans, they do not choose their Plan, and as a result, in light of TCPA, and potentially enormous financial penalties being assessed, plans have taken the position that they do not have consent from recipients to text them. And that is the problem.

Texting is the way most Americans communicate today. Other modalities like US mail (called snail mail for a reason), phone calls (who answers calls anymore?), and email (likely to go without a response for days or weeks) are dramatically less effective. Because they are low income, many Medicaid recipients often do not have a landline, or a laptop. They rely on their mobile phone for all their communication, including healthcare related communication. Texting is their preferred, and often only way of communicating.

As Founder and CEO for SameSky Health, I spent over a decade working with Plans to help them engage their members and navigate them into healthcare at the right time and the right place. Again and again, we found when we could maneuver around the outdated restrictions TCPA placed on Plans, we got higher engagement which translated into more well child visits, more breast cancer screenings, more diabetes (a1c) screenings, and so on. Using modern tools of communication is a way of meeting people where they are. It builds trust and leads to better health outcomes. But sadly, because of TCPA, we were not able to text members in most instances.

What has been a significant problem will be made exponentially worse when Federal Work Requirements are implemented as now seems likely. A Federal Medicaid Work requirement will dramatically increase the need to modernize how States and Plans communicate with Medicaid recipients. Compliance with TCPA is standing in the way of this modernization. And if it is not fixed, many, many people will lose their Medicaid benefits for purely procedural reasons.

To improve health outcomes, allow efficient communication to verify work status,  and provide twice yearly redetermination information, States and Plans must be exempted from the outdated provisions of TCPA. Senate action on, and final passage of the Reconciliation legislation offers the best opportunity to get an exemption from TCPA passed and signed into law.

The time to act is now.

So lets focus on (1) getting the exemption language in the Senate version of the Reconciliation legislation, (2) working with HHS and CMS to ensure post legislation guidance directs States and Plans to include texting as a best practice when implementing work requirement programs and communicating with recipients more generally, and (3) implementing a media strategy to build support for using modern technology to create easier more efficient ways for Medicaid recipients to comply with the new work requirements.

We have two months – June and July – to get action on an exemption in the Senate, and the remainder of the year to influence Administration guidance on work requirement programs.

Medicaid beneficiaries will be the biggest winners if we succeed because an exemption is a key strategy to reduce unnecessary loss of Medicaid benefits.

What can you do? Call your Senator and ask them to support modernizing how States and Plans communicate with Medicaid recipients. And please share this blog post with your network.

Abner Mason is Chief Strategy and Transformation Officer for GroundGame Health. He serves on the Board for Manifest MedEx, California’s largest health information exchange, is Vice-Chair of the Board for the California Black Health Network, and is a member of the National Commission on Climate and Workforce Health. Here are are just some of articles and interviews he has published over the past 10 years pushing for States and Plans to be able to text Medicaid recipients. 

Personal and Professional Choices in PSA Testing: A Teaching Moment

By KELLI DEETER  

I was intrigued by Daniel Stone’s piece on THCB in May titled “Biden’s cancer diagnosis as a teaching moment”. In my practice as a board-certified nurse practitioner, I am frequently asked about prostate specific antigen (PSA) testing by my male patients.  

Nursing practice and medical practice often get blurred or lumped together. In the state of Colorado, nurse practitioners practice under their own license, and can independently diagnose and treat patients. In some settings where I have worked, I found myself frequently correcting patients who refer to me as ‘doctor’. “I am not a medical  doctor, I am a nurse practitioner,” is repeated by me multiples of times per day. In this discussion of PSA testing, I want to share my decisions to order or not to order PSA testing for individuals, based on my nursing training.  

It is important to refer to the guidelines for PSA testing recommended by the US Preventive Services Task Force (USPSTF), and published by the Journal of the American Medical Association (JAMA). The last updates made to the guidelines were in 2018. It is key to remember that these are guidelines, and that medical doctors, physician assistants, and  nurse practitioners use these guidelines in their consideration of the patient. In nursing, a holistic and team approach with the patient’s preferences, history, cultural considerations, and desired outcome are all weighted in decision making for assessment, testing, referral, and treatment. Guidelines are just that, a GUIDE, not an absolute.  

Guidelines state that for patients aged 55-69: Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction… Clinicians should not screen men who do not express a preference for screening. And for patients  aged 70 and older: The USPSTF recommends against PSA-based screening for prostate cancer. This does not mean that we as providers should not test men younger than 55 or older than 70. We need to look at each patient case independently of one another and not  lump everyone together. 

Additionally, patients may not know how to “express a preference for  screening”. It is imperative that providers have the allotted time to explore their family history of prostate and other cancers, explain to them the benefits and risks of testing, listen to and discuss their signs and symptoms, perform a digital rectal exam (DRE) if appropriate and agreed on by the patient, take into consideration their medication regimen and their age, as well as if they would want treatment or not. Certainly, if they are symptomatic, and a new medication for their symptoms is being prescribed, or if they are symptomatic and a DRE is obtained that is abnormal, a PSA should be obtained with the  patient’s approval to establish a baseline, and a follow-up appointment made with repeat  labs or referral, if desired by the patient. If there is a family history of prostate cancer, an  early PSA screening test to establish a baseline might be preferable. Again, patient  preferences must be taken into account.  

People have very different feelings about western medicine and about what they want for  themselves and their bodies. We must realize that just because someone has an ever increasing PSA with or without symptoms, they may not agree to a DRE or to referral to  urology, surgery, or oncology. As a provider, we should obtain a refusal of recommended care. It is ok to not want testing, follow-up, or treatment, no matter one’s age. In Biden’s  case, there had been no PSA testing since 2014, during his vice presidency. The fact that no reason was given is irrelevant, in 2014 he was 72 years old. Guidelines are not to test  starting at age 70. The PSA level if drawn may not have aƯected his health outcome or  treatment, but it may have affected the outcome of his nomination for the presidency, thus politicizing nursing and medical practice. Pointing fingers now at the past changes nothing. I agree with Stone, that this is a teaching moment: advocate for yourself as a patient, advocate for your patient as a provider, and consider that so much of one’s health is a personal choice and that it should be honored and protected.  

I agree with Peter Attia’s contention in his May 24, 2024, A timely though tragic lesson on  prostate cancer screening, that the PSA screening guidelines are out of date; the last revision was in 2018. Attia indicates many men remain healthy and live well past the age of  80, and aggressive cancers if caught early and treated, will better benefit the patient’s quality of life and length of life. I would also argue this is true of screening earlier in life, at age 50. Access to health care is an issue for many in our society. Marginalized populations such as  the indigent, homeless, geriatric, mentally ill, and incarcerated experience greater  disparities, and have a higher risk of missing any PSA testing at all. In my work as a nurse  practitioner in the correctional system, for individuals entering jails and prisons this is  often the first time they have ever seen a healthcare provider. These individuals often have  a history of indigence, homelessness, and/or mental illness. Additionally, new cancer diagnoses are increasing and for men; 29% of new cancer types are prostate. 

Age 50 is a  milestone for most individuals, and they know they are supposed to get screening for colorectal cancer at this age as well as other screening tests. Consolidating care by capturing a PSA at this same time would establish an early baseline; there is never a guarantee that a patient with healthcare access issues will ever return for another appointment, due to finances, transportation, fear, or other factors. Another consideration for revising the PSA screening guidelines is lowering the threshold for PSA levels based on patient age that drive referral to urology for imaging, and putting simple language into the guidelines to look at a two-fold increase in PSA over 6-12 weeks as likely urgent referral to  urology. Initiating early watchful waiting with PSA screening has the potential for saving  more lives and maintaining desired qualities of life.

Kelli Deeter is a board-certified family nurse practitioner with 12 years of experience in geriatrics, rehabilitation, correction, women’s health, mental health, and complex chronic care.

Waste, Fraud and Abuse – Oh, My!

By KIM BELLARD

So the House has passed their “big, beautiful bill,” by the narrowest of margins. Crucial to the bill are large savings from Medicaid, which in past years Republicans would have taken some glee from but now they are careful to explain away as just cutting “waste, fraud and abuse,” having finally realized that many MAGA voters depend on Medicaid.

Much of those savings come from proposed work requirements for Medicaid recipients, long a favored Republican tactic that the Biden Administration kept rejecting. Speaker Mike Johnson is very vocal about their importance. The people impacted by the work requirements, he insisted on Face the Nation:

If you are able to work and you refuse to do so, you are defrauding the system. You’re cheating the system. And no one in the country believes that that’s right. So there’s a moral component to what we’re doing. And when you make young men work, it’s good for them, it’s good for their dignity, it’s good for their self-worth, and it’s good for the community that they live in.  

He’s convinced that, instead of working, too many of them – especially young men – “playing video games all day.” He and other Republicans want to return Medicaid to what they see as its original purpose: “It’s intended for young, you know, single, pregnant women and the disabled and the elderly,” Speaker Johnsom said. “But what’s happening right now is you have a lot of people, for example, young men, able-bodied workers, who are on Medicaid. They’re not working when they can.”

He’s generally right that, for most of its existence, Medicaid was not truly a program for the poor so much as for certain kinds of poor people, especially low income pregnant women and children, and the medically impoverished. It took Obamacare to widen coverage to all people under the poverty line, although the Supreme Court allowed states to decide if they wanted to do so, and ten states still have not.

It is, indeed, a moral question, just not the kind that Speaker Johnson likes, about whether there is a moral imperative to give more people, especially poor people, health coverage.  

The issue of these non-working Medicaid recipients is something of a shibboleth. Kaiser Family Foundation, for example, found “that 92% of Medicaid adults are either working (64%) or have circumstances that may qualify them for an exemption.” A 2023 CBO analysis cast doubt that such work requirements wouldn’t have much impact on the number of Medicaid recipients working. Work requirements are a solution in search of a problem.

Continue reading…

The Crawfish Chronicles: An NIH Fixed Cost Cap Parable

By GREGORY HOPSON

T-Maître Pierre’s Family Restaurant was a Louisiana institution. The kind of place where generations gathered over steaming mountains of boiled crawfish, spicy corn, and seasoned potatoes. A place where Clifton Chenier’s Louisiana Blues & Zydeco played in the background and the waitstaff wore starched white shirts with bright-colored bow ties. The walls were plastered with faded photos of people smiling. Nobody knew who they were anymore, but they felt like family.

Pierre Thibodeaux, the founder, made sure every customer was treated as if they were indeed family. So it was a bit ironic that when he passed away, he had no heirs. 

Within the week, the restaurant was acquired by multi-million-dollar developer O. B. Noxious, who addressed reporters beneath a banner that read:

MAKE CRAWFISH AMAZING AGAIN
“They call these little lobsters crawfish. Very smart. I like that. We’re keeping that name. Everything else? Outdated. Inefficient. Sad. We’re going to take this failing shack and turn it into the greatest restaurant the world has ever seen. People will come from everywhere and say, ‘Wow! I’ve never had crawfish this good. It’s the best anyone has ever tasted.’”

To oversee the transformation, Noxious brought in Otto Maladore, a consultant known for running billion-dollar companies and doing math in his head (where he also did all of his research).

Maladore spent thirty minutes walking the property, leaning over this, pressing on that, and stepping back from things while shaking his head. It wasn’t long before he issued his report to the press:

  • Excess Labor: “Wait staff, custodian, dishwasher? None of them cook so we’re wasting money on them. Eliminate all of those positions.”
  • Menu Simplification: “Boiled crawfish outsells everything. Eliminate everything else. Eliminate the menu itself. Menus are nothing more than administrative bloat.”
  • Décor: “We will have the best of everything. Those photos are faded and were low quality when they were new. Remove them.”
  • IT Modernization: “Found an IBM 5150 still running their books. This fascinates me-and concerns me-on so many different levels.”
  • Fixed Costs: “This place is hemorrhaging due to indirect costs. Forty percent of revenue on facilities and administration? That’s insane. Ten percent is more than enough for a place like this! But we’re far more generous and much more compassionate than people give us credit for. So we’re not going to cap it at 10%. We’re going to bump it all the way up to 15%!”

The changes happened quickly-literally overnight.

The next day when customers showed up, they found no music. No waiters. No ambiance. Just folding chairs, a beat-up old card table, and flickering fluorescent lights (they were told the remodeling would be done later). The walls were bare except for a sign that read:

T-MAÎTRE PIERRE’S CRAWFISH

READ CAREFULLY!!!!!!

  1. Proceed to the back parking lot and sign in.
    You will be assigned a ten-minute time slot for boiling.
  2. You will receive:
    a. Live crawfish
    b. Unshucked corn
    c. Potatoes (with high-quality dirt: pH between 6 and 6.5)
  3. Boiling pot pre-heated to exactly 212°F.
    DO NOT ADD OR REMOVE WATER!!!!!!
  4. Spice levels are pre-set.
  5. Extra napkins: $0.25 each
  6. IMPROPER DISPOSAL OF CORN HUSKS: 10% surcharge
  7. Failure to remove crawfish on time results in meal forfeiture.
    NO EXCEPTIONS, NO REFUNDS!!!!!

A middle-aged man in a Ragin’ Cajuns hat read the instructions aloud. Then he looked around at the solemn-looking patrons waiting in line behind him. The place was quiet except for a few muffled noises from the kitchen. He removed his cap, looked heavenward, paused, and muttered:

“Mais, ça, c’est pas bon.” (Man, this is no good.)

By the end of the week, two of the three chefs had had enough of renting pots and pans and arguing over burner rights. They moved to California, where a Chinese restaurant offered a fully equipped kitchen and covered indirect costs. Within weeks, they’d introduced Admiral Pierre’s Crawfish, featuring crawfish imported from China-descendants of Louisiana crawfish accidentally introduced there in the 1930s.

Back in Louisiana, the rain was coming down harder and the lone remaining chef was standing ankle-deep in a puddle, scolding a water-logged customer for being thirty seconds late getting his crawfish into the pot.

The Moral

This is what happens when outsiders impose arbitrary cost caps in the name of “efficiency.”

T-Maître Pierre’s didn’t fail because of bad crawfish. It failed because it lost the infrastructure that made the meal possible-pots, burners, tongs, and the people. The chef, once celebrated for his recipes and skill, now stands in the rain, powerless to cook without the tools he depended on. The recipes remain, but customers must now struggle to bridge the gaps themselves, leaving behind the joy and ease of a shared meal.

NIH’s Facilities and Administrative (F&A) cap is no different. It slashes funding for the very essentials that enable research to thrive: lab space, equipment, compliance staff, and the humans who know how to maintain complex machinery like autoclaves. Researchers, once empowered by infrastructure and expertise, are left to watch their innovations stall as benefactors scramble to piece together what’s missing.

At T-Maître Pierre’s, you’re stranded in the rain, struggling to figure out how to get crawfish boiled properly. And when you ask for help, the chef responds:

“Je suis l’uniq qui reste, pis ça c’est tout ce que j’ai.”
(I’m the only one left and this is all there is.)

Under NIH’s 15% cap, your research institution is trying to fund an autoclave by tearing its couch apart to find any loose change that may have fallen out of visitors’ pockets. And even that source is drying up-since PayPal and Venmo don’t have loose change.

Gregory Hopson works remotely from Baton Rouge, Louisiana as a Business Intelligence Developer for Emory Healthcare in Atlanta, Ga.

How Bright A Light Do We Shine This Memorial Day?

By MIKE MAGEE 

According to Veterans Administration historians, the origin of Memorial Day dates back to 1864 when three women from Boalsburg, Pennsylvania joined in grief to decorate the graves of family members who had died in the Civil War. A year later, other townspeople joined in and one year later, in 1866, women in Columbus, Mississippi, joined the event, in honor of fallen Confederate soldiers. That was 14 years after the publication of Harriet Beecher Stowe’s Uncle Tom’s Cabin in 1852. 

In that first year it was published, Uncle Tom’s Cabin sold over 300,000 copies. Author and critic Alfred Kazin called it “The most powerful and most enduring work ever written about American slavery.” Its prominence in the American lexicon speaks for itself, and its relevance regarding goodness and governance, leadership by legislation, women’s roles in creating civil societies and the underpinnings of Christianity in the unrealized potential of the American dream all speak to the continued value of the publication. 

On page 2 of the preface, Harriet Beecher Stowe comments on “memorializing” human hatred and cruelty to the ash bin of history. She writes, “It is a comfort to hope, as so many of the world’s sorrows and wrongs have, from age to age, been lived down, so a time shall come when sketches similar to these shall be valuable only as memorials of what has long ceased to be.” 

To this, we must respond today, “Not yet. There is work that remains.” 

On the last page of her book, Harriet Beecher Stowe in 1852 reflects (as if on our modern day predicament), “This is an age of the world when nations are trembling and convulsed. A mighty influence is abroad, surging and heaving the world, as with an earthquake. And is America safe? Every nation that carries in its bosom great and unredressed injustice has in it the elements of this last convulsion.”

To this, we believers in human goodness and democracy must respond, “We will never be free, safe and healthy if our elected leaders promote policies – whether here or abroad – that belie our finer instincts, promote fear, and trigger predation.” 

The White House, until recently, has largely been a sacred and treasured shrine. Back in 2013, our President at the time, Barack Obama, hosted our former President, George H.W. Bush and his family there to commemorate the 5000th award of a “Daily-Point-of-Light”, that the former President had launched to “honor individuals who demonstrate the transformative power of service, and who are driving significant and sustained impact through their everyday actions and words that light the path for other points of light.” 

Here in part, is what President Obama said that day: “…given the humility that’s defined your life, I suspect it’s harder for you to see something that’s clear to everybody else around you, and that’s how bright a light you shine — how your vision and example have illuminated the path for so many others, how your love of service has kindled a similar love in the hearts of millions here at home and around the world. And, frankly, just the fact that you’re such a gentleman and such a good and kind person I think helps to reinforce that spirit of service. So on behalf of us all, let me just say that we are surely a kinder and gentler nation because of you and we can’t thank you enough.” 

Just a dozen years ago, just to be publicly “thanked” seemed enough. And “active citizenship” as a member of this great nation was viewed by many – by most – as a duty and an honor – even to the point of sacrificing one’s life in defense of this nation. 

That, after all, is what Memorial Day commemorates. Action is required, as is goodness and virtue by example and daily behavior. 

We continue to struggle in the shadow of Uncle Tom’s Cabin. We lack perfection, but we certainly could, and should, do better. Because, to be healthy in America, to realize our full potential, to be civilized, as Ralph Waldo Emerson said, “to make good the cause of freedom against slavery you must be… Declaration of Independence walking.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

This One Weird Trick Can Fix U.S. Healthcare

By OWEN TRIPP

Creating a healthcare experience that builds trust and delivers value to people and purchasers isn’t a quick fix, but it’s the only way to reverse the downward spiral of high costs and poor outcomes

Entrepreneurs like to say the U.S. healthcare system is “broken,” usually right before they explain how they intend to fix it. I have a slightly different diagnosis.

The U.S. healthcare system is the gold standard. Our institutions and enterprises, ranging from 200-year-old academic medical centers to digital health startups, are the clear world leaders in clinical expertise, research, innovation, and technology. Capabilities-wise, the system is far from broken.

What’s broken is trust in the system, because of the glaring gap between what the system is capable of and what it actually delivers. Every day across the country, people drive past world-class hospitals, but then have to wait months for a primary care appointment. They deduct hundreds for healthcare from each paycheck, only to be told at the pharmacy that their prescription isn’t covered. While waiting for a state-of-the-art scan, they’re handed a clipboard and asked to recap their medical history.

This whipsaw experience isn’t due to incompetence or poor infrastructure. It’s the product of the dysfunction between the two biggest players in healthcare: providers and insurers, two entities that have optimized the hell out of their respective businesses, in opposition to one another, and inadvertently at the expense of people.

Historically, hospitals and health systems — including those 200-year-old AMCs — have dedicated themselves fully to improving and saving lives. I’m not saying they’ve lost sight of this, but until recently, margin took a back seat to mission. With industry consolidation and the persistence of the fee-for-service model, however, providers’ hands have been forced to maximize volume of care at the highest possible unit cost, which in turn has become a main driver of the out-of-control cost trend at large.

This push from providers has prompted an equal-and-opposite reaction from insurers. Though the industry has been villainized (rightly, in some cases) for a heavy-handed approach to utilization management and prior authorization, insurers are merely doing what their primary customers — private employers — have hired them to do: manage cost. Insurers have gotten very good at it, not just by limiting care, but also through product innovation that has created more tiers and cost-sharing options for plan sponsors.

Meanwhile, healthcare consumers (people!) have been sidelined amid this tug-of-war. Doctors and hospitals say they’re patient-centered, and insurers say they’re member-centric — but the jargon is a dead giveaway. Each side is focused on their half of the pie, and neither is accountable for the whole person: the person receiving care and paying for care, not to mention navigating everything in between.

It should come as no surprise that trust is falling. Only 56% of Americans trust their health insurer to act in their best interest. Even trust in doctors — the good guys — has plummeted. In a startling reversal from just four years ago, a whopping 76% of people believe hospitals care more about revenue than patient care.

Loss of Trust in Healthcare Providers

Hospitals in the U.S.
are mostly focused on…
⏺  Caring for patients⏺  Making money


Source: Jarrard/Chartis (2025)

This trust deficit is the root cause of so many healthcare problems. It’s the reason people disengage, delay and skip care, and end up in the ER or OR for preventable issues. When a good chunk of the population falls into this cycle, as they have, you end up with the status quo: unrelenting costs and deteriorating outcomes that is dragging down households, businesses, and the industry itself.

There’s no quick fix. Despite what my fellow entrepreneurs might say, no one point solution or technology (no, not even AI) can rebuild trust. The only way to reverse the downward spiral is by serving up a modern experience that is genuinely designed around people’s needs.

Continue reading…

Patrick Quigley, Sidecar Health

Patrick Quigley is the CEO of Sidecar Health. It’s a start up health insurance company that has a new approach to how employers and employees buy health care. Sidecar is betting on the radical pricing  transparency idea. Instead of going down the contacting and narrow network route, Sidecar presents average area pricing and individual provider pricing to its members, and rewards them if they go to lower cost providers (who often are cheaper). How does this all work and is it real? Patrick took me through an extensive demo and explained how this all works. There’s a decent amount of complexity behind the scenes but Sidecar is creating something very rare in America, a priced health care market allowing consumers to choose–Matthew Holt

Tracy DeTomasi, Callisto

Callisto is a non-profit tech company that helps survivors of sexual violence identify repeat offenders. The company was started a few years back by Jess Ladd and Tracy DeTomasi took over as CEO a few years back, It focuses on college campuses where 90% of assaults are perpetrated by repeat offenders, who on average commit 6 offenses. And 90% of assaults are not reported, Callisto is working providing an anonymous solution with Tracey also giving a demo of how it works. This is a  tough conversation about a difficult topic.–Matthew Holt

When Star Ratings Backfire: How CMS Could Better Support Health In Medicare Advantage

By EMMANUEL ANIMASHAUN

The Centers for Medicare & Medicaid Services (CMS) Star Ratings system represents a cornerstone of quality assessment in Medicare Advantage (MA), designed to empower consumers with transparent information while rewarding plans that deliver superior care. Yet recent developments, particularly the seismic downgrading of Humana’s ratings reveal an unintended consequence: a system created to measure and incentivize quality may now be actively undermining it.

The Humana Case: Symptom of a Broader Problem

In 2025, Humana’s Medicare Advantage star ratings collapsed, with only 25% of members remaining in four-star or higher plans, down from 94%. This wasn’t due to declining clinical performance but resulted from CMS’s “Tukey outlier deletion” statistical adjustment implemented with minimal industry consultation. The change raised performance thresholds, causing Humana to lose billions in Quality Bonus Payments and $4 billion in market value. Humana’s legal challenge, arguing that CMS violated the Administrative Procedure Act through non-transparent processes, was denied. Other insurers including UnitedHealthcare and Centene also share concerns about methodological rigidity and that the rating system may have diverged from its purpose of improving patient care.

Perhaps more striking are the cases of Elevance and SCAN, which further illustrate how rigid metrics can distort assessments of actual care quality. In March 2023, both insurers were penalized after allegedly missing a single CMS “secret shopper” phone call, a call they claim was never received. The downgrade cost them tens of millions in Quality Bonus Payments and triggered legal challenges. As SCAN’s CEO wrote, the sanction came despite strong clinical performance and patient outcomes. A federal judge later ruled in favor of SCAN in June 2024, prompting CMS to recalculate the Star Ratings across all Medicare Advantage plans. This episode underscores a key concern: when measurement hinges on unverifiable administrative moments, it may end up punishing rather than promoting quality.

How Quality Measurement Can Undermine Actual Quality

The Star Ratings system aggregates over 40 metrics across preventive care, medication adherence, member experience, and customer service. However, it disproportionately rewards process compliance and documentation over health outcomes. Plans can excel by optimizing coding, maximizing documentation, or boosting survey participation without delivering better care. This misalignment diverts resources from genuine health innovations. Research from an NBER working paper even found that better-rated plans aren’t statistically better at keeping patients alive than lower-rated ones, raising fundamental questions about whether the system measures what truly matters for patient health.

Even more concerning is that MA contracts with higher proportions of dually eligible, disabled, or racially diverse members consistently score lower, not because they provide inferior care, but because the scoring system inadequately adjusts for social risk factors. A JAMA Health Forum study highlighted how plans serving more Black beneficiaries had lower star ratings even when controlling for other factors. This structural bias effectively penalizes plans doing the challenging work of serving populations with complex needs, creating a perverse disincentive to focus on health equity.

The uncertainty from frequent changes in star rating computation could also pose severe implications for strategic planning for companies. When a company like Humana loses billions due to a technical recalibration, it sends a troubling message: long-term investments in quality improvement may not yield returns if measurement methodologies change unpredictably. This volatility makes strategic planning difficult and discourages sustained investment in quality initiatives.

The Real-World Impact on Patients

These methodological shortcomings do not just affect health plans’ bottom lines; they have tangible consequences for Medicare beneficiaries. When plans lose Quality Bonus Payments (QBPs), they often must scale back valuable supplemental benefits like transportation assistance, dental coverage, or in-home support services, or increase plan premiums, as Avalere Health suggests. McKinsey estimates CMS rating changes could cost plans over $800 million in bonuses, reducing resources available for such benefits.

Continue reading…

Medicaid Budget Cuts: Hospitals will bear the burden, we will pay the price

By LINDA RIDDELL & THOMAS WILSON

Recent discussions over Medicaid budget cuts invite us to look more deeply into the house-of-cards that, when it collapses, will hit the states and low-income households hardest. But we will all be harmed.

Some states get 80% of their Medicaid funding from the federal government, as a recent Wall Street Journal article, “Medicaid Insures Millions of Americans. How the Health Program Works, in Charts” pointed out. Even states relying less on federal funds will be hard pressed to shift their resources to replace the federal share. The ripple effects are clear: states are likely to reduce Medicaid enrollment, forcing low-income people to skip care or find free care, and hospitals will shift resources to cover care they are not paid for. Dollars cut from Medicaid do not vanish; they simply shift to different corners of the healthcare system. Ouch!

A Deep Dive into the Facts

Fact 1. Low-Income Households Already Spend More of Their Income on Health Care: Recent Consumer Expenditure Survey data reveals that the lowest 20% of households—roughly corresponding to those enrolled in Medicaid—saw the share of their income spent on healthcare (red in Figure below) rise from 8% in 2005 to 11% in 2023. In contrast, the highest-income 20% devoted only 2% in 2005, rising to about 4% of their income to healthcare in 2023.

Fact 2. Necessities Consume a Majority of Low-Income Households’ Income: Low-income households spend about 57% of their income on essentials like food and housing (blue in figure). This leaves little to nothing for other expenses. These families have an almost inelastic budget where any additional expense, even one as critical as medical care, forces painful trade-offs. In contrast, high-income households have from 38% to 53% of their income (purple in figure) left over after meeting all basic and other costs.

Fact 3. Affordable Care Act Led to Reduced Uninsured ED Visits: In 2016 — two years after Affordable Care Act provisions took effect —  many states expanded Medicaid, and all introduced health insurance exchanges. These changes brought emergency department visits by uninsured patients down by half—from 16% to 8%.

Fact 4. Uncompromising Obligations at Hospitals: Under the U.S. Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must treat and stabilize every patient who arrives, regardless of their ability to pay. With around 70% of all hospital admissions arriving via the ED, a surge in uncompensated care in the ED will directly affect admission rate, the hospital’s core function.

Examining the Key Inferences

Inference 1. Rising Uninsured Populations: Cutting Medicaid budgets is likely to lead to states shrinking enrollment and boosting the number of uninsured individuals.

Inference 2. A Resurgence in Uninsured ED Visits: If Medicaid budget cuts reduce enrollment, the previously achieved reductions in uninsured ED visits could return to the high rates seen before the ACA.

Inference 3. Hospitals Caught in the Crossfire: Budget cuts will force hospitals to provide more uncompensated ED care. The response is likely to be reducing staff, the hospital’s largest cost center  — a move that directly affects the quality and timeliness of both primary and specialty services. Washington state offers a cautionary tale, where hospital leaders predict longer wait times and lower service levels due to state budget cuts.

Broad Impacts Beyond the Numbers

The health system must pick up the $880 billion slack, not by magically creating money but by shifting resources from other programs.  The healthcare system has its priorities set by the budget scramble–not by the community’s health needs. Health disparities between the rich and poor will widen, and progress made on having more people insured will reverse.

Staff cuts will lengthen wait times and decrease service quality, not to mention they will burn more people out of their health service jobs. The ripple effects of Medicaid cuts will eventually touch all who seek medical care and pay for health insurance.

A Call for Political and Community Action

Now, more than ever, it is time for political stakeholders to recognize that the real cost of Medicaid cuts is borne not just by states but also by communities. Stakeholders, policymakers, community leaders, and the general public must stand up for their own interest in having a sustainable health care funding approach.

Toward a More Equitable Future

The case against Medicaid budget cuts is not merely about dollars and cents—it is about the future of our healthcare system and the health of millions of Americans. Cutting Medicaid benefits may create short-term savings on paper, but it undermines the health infrastructure that serves everyone.

A thoughtful and balanced approach would protect vulnerable populations while ensuring hospitals remain viable centers of care, especially for rural areas. In rural communities, the health sector creates 14% of jobs; rural hospitals are generally the largest employer and since they serve more Medicaid and Medicare patients, they will be the hardest hit by these budget cuts.

The shift in where healthcare dollars are spent could change every layer of healthcare delivery—from the ED’s ever-growing responsibility to inpatient admissions to primary care’s dwindling resources. It is a call for all of us to rethink how healthcare is funded and to stand in solidarity with those at risk of being left without medical care.

Looking Ahead

Beyond the immediate fiscal challenges, this issue invites a broader discussion on healthcare reform. How can we restructure funding to improve efficiencies? Could community health cooperatives or expanded telehealth services help lessen adverse effects?  These questions deserve robust debate and decisive action.

In these turbulent times, every stakeholder—from local communities to federal policymakers— needs to find solutions that prioritize human health over short-term budget tactics. The stakes are high, and the choices made today will shape healthcare access and quality for decades to come.

Linda Riddell, MS is a population health scientist specializing in poverty and is the founder of Gettin’ By, a training tool helping teachers, doctors, case managers, and others work more effectively with students, patients and clients who are experiencing poverty. Thomas Wilson, PhD, DrPH is an epidemiologist focused on real-world issues and board chair of the non-profit Population Health Impact Institute