Black Americans Still Suffer Worse Health. Here’s Why There’s So Little Progress.
KINGSTREE, S.C. — One morning in late April, a small brick health clinic along the Thurgood Marshall Highway bustled with patients.
There was Joshua McCray, 69, a public bus driver who, four years after catching covid-19, still is too weak to drive.
Louvenia McKinney, 77, arrived complaining about shortness of breath.
Ponzella McClary brought her 83-year-old mother-in-law, Lula, who has memory issues and had recently taken a fall.
Morris Brown, the family practice physician who owns the clinic, rotated through Black patients nearly every 20 minutes. Some struggled to walk. Others pulled oxygen tanks. And most carried three pill bottles or more for various chronic ailments.
But Brown called them “lucky,” with enough health insurance or money to see a doctor. The clinic serves patients along the infamous “Corridor of Shame,” a rural stretch of South Carolina with some of the worst health outcomes in the nation.
“There is a lot of hopelessness here,” Brown said. “I was trained to keep people healthy, but like 80% of the people don’t come see the doctor, because they can’t afford it. They’re just dying off.”
About 50 miles from the sandy beaches and golf courses along the coastline of this racially divided state, Morris’ independent practice serves the predominantly Black town of roughly 3,200 people. The area has stark health care provider shortages and high rates of chronic disease, such as diabetes, high blood pressure, and heart disease.
But South Carolina remains one of the few states where lawmakers refuse to expand Medicaid, despite research that shows it would provide medical insurance to hundreds of thousands of people and create thousands of health care jobs across the state.
The decision means there will be more preventable deaths in the 17 poverty-stricken counties along Interstate 95 that constitute the Corridor of Shame, Brown said.
“There is a disconnect between policymakers and real people,” he said. The African Americans who make up most of the town’s population “are not the people in power.”
The U.S. health care system, “by its very design, delivers different outcomes for different populations,” said a June report from the National Academies of Sciences, Engineering, and Medicine. Those racial and ethnic inequities “also contribute to millions of premature deaths, resulting in loss of years of life and economic productivity.”
Over a recent two-decade span, mounting research shows, the United States has made almost no progress in eliminating racial disparities in key health indicators, even as political and public health leaders vowed to do so.
And that’s not an accident, according to academic researchers, doctors, politicians, community leaders, and dozens of other people KFF Health News interviewed.
Federal, state, and local governments, they said, have put systems in place that maintain the status quo and leave the well-being of Black people at the mercy of powerful business and political interests.
Across the nation, authorities have permitted nearly 80% of all municipal solid waste incinerators — linked to lung cancer, high blood pressure, higher risk of miscarriages and stillbirths, and non-Hodgkin lymphoma — to be built in Black, Latinx, and low-income communities, according to a complaint filed with the federal government against the state of Florida.
Federal lawmakers slowed investing in public housing as people of color moved in, leaving homes with mold, vermin, and other health hazards.
And Louisiana and other states passed laws allowing the carrying of concealed firearms without a permit even though gun violence is now the No. 1 killer of kids and teens. Research shows Black youth ages 1 to 17 are 18 times as likely to suffer a gun homicide as their white counterparts.
“People are literally dying because of policy decisions in the South,” said Bakari Sellers, a Democratic former state representative in South Carolina.
KFF Health News undertook a yearlong examination of how government decisions undermine Black health — reviewing court and inspection records and government reports, and interviewing dozens of academic researchers, doctors, politicians, community leaders, grieving moms, and patients.
From the cradle to the grave, Black Americans suffer worse health outcomes than white people. They endure greater exposure to toxic industrial pollution, dangerously dilapidated housing, gun violence, and other social conditions linked to higher incidence of cancer, asthma, chronic stress, maternal and infant mortality, and myriad other health problems. They die at younger ages, and covid shortened lives even more.
Disparities in American health care mean Black people have less access to quality medical care, researchers say. They are less likely to have health insurance and, when they seek medical attention, they report widespread incidents of discrimination by health care providers, a KFF survey shows. Even tools meant to help detect health problems may systematically fail people of color.
All signs point to systems rooted in the nation’s painful racist history, which even today affects all facets of American life.
“So much of what we see is the long tail of slavery and Jim Crow,” said Andrea Ducas, vice president of health policy at the Center for American Progress, a nonprofit think tank.
Put simply, said Jameta Nicole Barlow, a community health psychologist and professor at George Washington University, government actions send a clear message to Black people: “Who are you to ask for health care?”
Past and Present
The end of slavery gave way to laws that denied Black people in the U.S. basic rights, enforced racial segregation, and subjected them to horrific violence.
“I can take facts from 100 years ago about segregation and lynchings for a county and I can predict the poverty rate and life expectancy with extraordinary precision,” said Luke Shaefer, a professor of social justice and public policy at the University of Michigan.
Starting in the 1930s, the federal government sorted neighborhoods in 239 cities and deemed redlined areas — typically home to Black people, Jews, immigrants, and poor white people — unfit for mortgage lending. That process concentrated Black people in neighborhoods prone to discrimination.
Local governments steered power plants, oil refineries, and other industrial facilities to Black neighborhoods, even as research linked them to increased risks of cardiovascular and respiratory diseases, cancer, and preterm births.
The federal government did not even begin to track racial disparities in health care until the 1980s, and at that time disparities in heart disease, infant mortality, cancer, and other major categories accounted for about 60,000 excess deaths among Black people each year. Elevated rates of six diseases, including cancer, addiction, and diabetes, accounted for more than 80% of the excess mortality for Black and other minority populations, according to “The Heckler Report,” released in 1985. During the past two decades there have been 1.63 million excess deaths among Black Americans relative to white Americans. That represents a loss of more than 80 million years of life, according to a 2023 JAMA study.
Recent efforts to address health disparities have run headlong into racist policies still entrenched in health systems. The design of the U.S. health care system and structural barriers have led to persistent health inequities that cost more than a million lives and billions of dollars, according to the national academies report.
“When covid was first hitting, it was just sort of immediately clear who was going to suffer the most,” Ducas said, “not just because of differential access to care, but who was in a living environment that’s multigenerational or crowded, who is more likely to be in a job where they are an essential worker, who is going to be more reliant on public transportation.”
For example, in spring 2020, the North Carolina health department, led by current Centers for Disease Control and Prevention Director Mandy Cohen, failed to get covid testing to vulnerable Black communities where people were getting sick and dying from covid-related causes at far higher rates than white people.
And Black Americans were far more likely to hold jobs — in areas such as transportation, health care, law enforcement, and food preparation — that the government deemed essential to the economy and functioning of society, making them more susceptible to covid, according to research.
Until McCray, the bus driver in Kingstree, South Carolina, got covid in his mid-60s, he was strong enough to hold two jobs. He ended up on a feeding tube and a ventilator after he contracted covid in 2020 while taking other essential workers from this predominantly Black area to jobs in a whiter, wealthier tourist town.
Now he cannot work and at times has difficulty walking.
“I can tell you the truth now: It was only the good Lord that saved him,” said Brown, the rural physician who treated McCray and many patients like him.
Federal and state governments have spent billions of dollars to implement the Affordable Care Act, the Children’s Health Insurance Program, and other measures to increase access to health care. Yet, experts said, many of the problems identified in “The Heckler Report” persist.
When Lakeisha Preston in Mississippi was diagnosed with walking pneumonia in 2019, she ended up with a $4,500 medical bill she couldn’t pay. Preston works at Maximus, which has a $6.6 billion contract with the federal government to help people sign up for Medicare and Affordable Care Act health plans.
She is convinced that being a Black woman made her challenges more likely.
“Think about how many centuries the same thing has been happening,” said Preston, noting how her mother worked two jobs her entire life without a vacation and suffered from health conditions including diabetes, cataracts, and carpal tunnel syndrome. Today Preston can’t afford to put her 8-year-old son on her health plan, so he’s covered by Medicaid.
“We consistently offer healthcare plans that are on par, if not better, than those available to most Americans through state and federal exchanges,” said Eileen Cassidy Rivera, a Maximus spokesperson.
In email exchanges with the Biden administration, spokespeople insisted that it is making progress in closing the racial health gap. They said officials have taken steps to address food insecurity, housing instability, pollution, and other social determinants of health that help fuel disparities.
President Joe Biden issued an executive order on his first full day in office in 2021 that said “the COVID-19 pandemic has exposed and exacerbated severe and pervasive health and social inequities in America.” Later that year, the White House issued another executive order focused on improving racial equity and acknowledged that long-standing racial disparities in health care and other areas have been “at times facilitated by the federal government.”
“The Biden-Harris Administration is laser focused on addressing the health needs of Black Americans by dismantling persistent structural inequities,” said Renata Miller, a spokesperson for the administration.
The CDC, along with some state and local governments, declared racism a serious public health threat.
U.S. Rep. Alma Adams, a North Carolina Democrat, pushed for “Momnibus” legislation to reduce maternal mortality. Yet federal lawmakers left money for Black maternal health out of the historic Inflation Reduction Act in 2022.
“I come to this space as an elected official, knowing what it is like to be poor, knowing what it is like to not have insurance and having to get up at 3, 4 in the morning with my mom to take my sister to the emergency room,” Adams said.
In the 1960s in North Carolina, Adams and her family would take her sister Linda, who had sickle cell anemia, to the emergency room because they had no doctor and could not afford health insurance. Linda died at the age of 26 in 1971.
“You have to have some sensitivity for this work,” Adams said. “And a lot of folks that I’ve worked with don’t have it.”
Governor’s Veto
The website for Kingstree depicts idyllic images of small-town life, with white people sitting on a porch swing, kayaking on a river, eating ice cream, and strolling with their dogs. Two children wearing masks and a food vendor are the only Black people in the video, even though Black people make up 70% of the town’s population.
But life in Kingstree and surrounding communities is marked by poverty, a lack of access to health care, and other socioeconomic disadvantages that have given South Carolina poor rankings in key health indicators such as rates of death and obesity among children and teens.
Some 23% of residents in Williamsburg County, which contains Kingstree, live below the poverty line, about twice the national average, according to federal data.
There is one primary care physician for every 5,080 residents in Williamsburg County. That’s far less than in more urbanized and wealthier counties in the state such as Richland, Greenville, and Beaufort.
Edward Simmer, the state’s interim public health director, said that if “you are African American in a rural zone, it is like having two strikes against you.”
Asked if South Carolina should expand Medicaid, Simmer said the challenges South Carolina and other states confront are worsened by health care provider shortages and structural inequities too large and complicated for Medicaid expansion alone to solve.
“It is not a panacea,” he said.
But for Brown and others, the reason South Carolina remains one of the few states that have not expanded Medicaid — one step that could help narrow disparities with little cost to the state — is clear.
“Every year we look at the data, we see the health disparities and we don’t have a plan to improve,” Brown said. “It has become institutionalized. I call it institutional racism.”
A July report from George Washington University found that Medicaid expansion would provide insurance to 360,000 people and add 18,000 jobs in the health care sector in South Carolina.
“Racism is the reason we don’t have Medicaid expansion. Full stop,” said Janice Probst, a former director of the Rural and Minority Health Research Center in South Carolina. “These are not accidents. There is an idea that you can stay in power by using racism.”
South Carolina’s Republican governor, Henry McMaster, in July vetoed legislation that would have created a committee to consider Medicaid expansion, saying he did not believe it would be “fiscally responsible.”
Expanding Medicaid in the state could result in $4 billion in additional economic output from an influx of federal funds in 2026, according to the July report.
Beyond health care coverage and provider shortages, Black people “have never been given the conditions needed to thrive,” said Barlow, the George Washington University professor. “And this is because of white supremacy.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Voters Fret High Medical Bills Are Being Ignored by Presidential Rivals
Tom Zawierucha, 58, a building services worker in New Jersey, wishes candidates would talk more about protecting older Americans from big medical bills.
Teresa Morton, 43, a freight dispatcher in Memphis, Tennessee, with two teenagers, wants to hear more about how elected officials would help working Americans saddled with unaffordable deductibles.
Yessica Gray, 28, a customer support representative in Wisconsin, craves relief from high drug prices and medical bills that have driven her and her husband deep into debt. “How much are we going to pay?” she said. “It’s just something that’s always on my mind.”
Health care hasn’t figured prominently in this increasingly acrimonious presidential campaign. And the economy has generally topped the list of voters’ concerns.
But Americans remain intensely worried about paying for medical care, national surveys show.
Two in 3 U.S. adults in a recent nationwide poll by West Health and Gallup said they’re concerned a major health event would land them in debt. A similar share said health care isn’t getting enough attention in the campaign.
To better understand voters’ health care concerns as the 2024 campaign nears an end, KFF Health News worked with research firm PerryUndem, which convened a pair of focus groups last week with 16 people from across the country. PerryUndem, which paid to organize the focus groups, is a nonpartisan firm based in Washington, D.C., that studies public views on health care and other issues.
The focus group participants represented a broad swath of the electorate, with some favoring Republican candidates, and others Democrats. But nearly all shared a common complaint: Neither presidential candidate has talked enough about how they’d help people struggling to pay for medical care.
“You don’t really hear anything much about health care costs,” said Bob Groegler, 46, who works in residential financing in eastern Pennsylvania. Groegler said he’s worried he may never be able to retire because he won’t have enough money to pay his medical bills.
Former President Donald Trump, the Republican nominee, hasn’t offered a detailed health care agenda, though he criticizes current laws and said he has “concepts of a plan” to improve the 2010 Affordable Care Act, often called Obamacare.
Vice President Kamala Harris, a Democrat, has laid out more detailed health care proposals, including building on legislation signed by President Joe Biden to lower patients’ bills.
In 2022, Biden signed the Inflation Reduction Act, which limits how much Medicare enrollees must pay out-of-pocket for prescription drugs, including a $35 monthly cap on insulin. The legislation also provides additional federal aid to help Americans buy health insurance through the Affordable Care Act, though this aid will expire unless Congress and the president renew it next year.
Harris has said she will expand the aid and push for new assistance to Medicare enrollees who need home care. She also has pledged to continue federal efforts to relieve medical debt, a nationwide problem that burdens about 100 million people.
But most of the focus group participants said they knew little about these proposals, complaining that hot-button issues like abortion have dominated the campaign.
Many also expressed deep skepticism that either Harris or Trump would do much to lighten the burden of medical bills.
“I believe they’re out of touch with our reality,” said Renata Bobakova, 46, a teacher and mother outside Cleveland. “We never know when we’ll get sick. We never know when we’ll fall down or sprain an ankle. And prices really can be astronomical. … I’m constantly worried about that.”
Bobakova, who is from Slovakia, said she went back to Europe to give birth to her daughter 10 years ago to avoid crippling medical debt she knew she’d incur in this country. Parents with private health coverage face on average more than $3,000 in medical bills related to a pregnancy and childbirth that aren’t covered by insurance.
Other focus group participants said they or people they knew had left the country to get cheaper prescription drugs. The U.S. has the highest medical prices in the world, research shows.
Several focus group participants, such as Kevin Gaudette, 64, a retired semiconductor engineer in North Carolina, blamed large hospitals, drug companies, and insurers for blocking efforts to lower patients’ costs to protect their profits. “I think everybody has their finger in the pie,” Gaudette said.
Martha Chapman, 64, who is also retired and lives in Philadelphia, pointed to what she called “corporate greed.” “I just don’t think it’s going to change,” she said.
In the closing days of the campaign, that cynicism represents a particular problem for Harris, said PerryUndem co-founder Michael Perry, who led the two focus groups.
Harris has tried to distinguish herself as the candidate who is more serious about policy and more sympathetic to voters’ economic struggles, Perry said. And in recent weeks, she’s begun airing new ads highlighting health care issues.
But even focus group participants who said they lean Democratic seemed to blame both candidates for not addressing Americans’ health care concerns. “They’re not feeling listened to,” Perry said.
Many of the participants nevertheless continued to express hope that an issue as important as health care would someday get the attention of elected officials, regardless of political party.
“We’re all human beings here. We’re all people just trying to make it,” said Zawierucha, the building services worker in New Jersey. “If we get sick or have to go in and get something done, we should have that peace of mind that we can go in there and not have to worry about paying it off for the next 20 years.”
“Just give us some peace of mind,” he said.
[Clarification: This article was revised at 11:35 a.m. ET on Oct. 24, 2024, to more clearly describe how the focus groups were organized.]
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Beneficiarios de Medicare gastarán menos en medicamentos en 2025
Cuando Pam McClure se enteró que el próximo año ahorraría casi $4,000 en sus medicamentos recetados dijo: “parece demasiado bueno para ser verdad”.
Para finales de 2024, habrá gastado casi $6,000 en estos fármacos, incluido uno para controlar su diabetes.
McClure, de 70 años, es una de las aproximadamente 3.2 millones de personas con un plan de medicamentos recetados de Medicare cuyos costos de bolsillo se limitarán a $2,000 en 2025 gracias a la Ley de Reducción de la Inflación (IRA, por sus siglas en inglés) de 2022 promulgada por la administración Biden, según un estudio de Avalere/AARP.
La IRA, una ley de atención médica y clima que el presidente Joe Biden y la vicepresidenta Kamala Harris promueven en la campaña como uno de los mayores logros de su administración, rediseñó radicalmente el beneficio de medicamentos de Medicare, conocido como Parte D, que sirve a unas 53 millones de personas de 65 años o más, o que viven con ciertas discapacidades.
Gracias a este nuevo límite en el gasto de bolsillo y otros cambios importantes, pero menos conocidos, la administración estima que alrededor de 18.7 millones de personas ahorrarán aproximadamente $7.4 mil millones solo el próximo año.
El período de inscripción anual para que los beneficiarios de Medicare renueven o cambien su cobertura de medicamentos, o elijan un plan Medicare Advantage, comenzó el 15 de octubre y se extiende hasta el 7 de diciembre. Medicare Advantage es la alternativa comercial al Medicare tradicional administrado por el gobierno y cubre atención médica y, a menudo, medicamentos recetados.
Los planes de medicamentos independientes de Medicare, que cubren medicamentos que normalmente se toman en casa, también son administrados por compañías de seguros privadas.
“Siempre alentamos a los beneficiarios a que realmente revisen los planes y elijan la mejor opción para ellos”, dijo Chiquita Brooks-LaSure, quien dirige los Centros de Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), a KFF Health News. “Y este año, en particular, es importante hacerlo porque el beneficio ha cambiado mucho”.
Las mejoras a la cobertura de medicamentos de Medicare requeridas por la IRA son los cambios más importantes desde que el Congreso agregó el beneficio en 2003, pero la mayoría de los votantes no los conocen, según encuestas de KFF, una organización sin fines de lucro de información sobre salud que incluye a KFF Health News. Y algunos beneficiarios pueden sorprenderse por un inconveniente: algunos planes aumentarán sus primas.
El 27 de septiembre, los CMS dijeron que, a nivel nacional, la prima promedio de los planes de medicamentos de Medicare disminuyó alrededor de $1.63 al mes —aproximadamente un 4%— respecto al año pasado.
“Las personas inscritas en un plan de la Parte D de Medicare seguirán viendo primas estables y tendrán amplias opciones de planes asequibles”, dijeron los CMS en un comunicado.
Sin embargo, un análisis de KFF encontró que “muchas aseguradoras están aumentando las primas” y que grandes aseguradoras como UnitedHealthcare y Aetna también redujeron la cantidad de planes que ofrecen.
Las propuestas iniciales de primas de muchas aseguradoras de la Parte D para 2025 fueron aún más altas. Para amortiguar el impacto del precio, la administración Biden creó lo que llama un programa de demostración para pagar a las aseguradoras $15 adicionales al mes por beneficiario si aceptaban limitar los aumentos de primas a no más de $35.
“En ausencia de esta demostración, los aumentos de primas ciertamente habrían sido mayores”, escribió Juliette Cubanski, subdirectora del Programa de Políticas de Medicare en KFF, en su análisis del 3 de octubre.
Casi todas las aseguradoras de la Parte D aceptaron el acuerdo. Los republicanos lo han criticado, cuestionando la autoridad de los CMS para hacer los pagos adicionales y llamándolos una maniobra política en un año electoral.
Sea cual sea la razón, las primas están subiendo dramáticamente para algunos planes.
En el estado de Nueva York, por ejemplo, la prima del popular plan Value Script de Wellcare pasó de $3.70 mensuales a $38.70 el próximo año, un aumento de $35, más de diez veces que el costo actual.
Cubanski identificó ocho planes en California que aumentaron sus primas exactamente $35 al mes. KFF Health News encontró que las primas aumentaron en al menos el 70% de los planes de medicamentos ofrecidos en California, Texas y Nueva York, y en alrededor de la mitad de los planes en Florida y Pennsylvania, los cinco estados con más beneficiarios de Medicare.
Voceros de Wellcare y de su empresa matriz, Centene Corp., no respondieron a las solicitudes de comentarios. En una declaración este mes, la vicepresidenta senior de servicios clínicos y especializados de Centene, Sarah Baiocchi, dijo que Wellcare ofrecería el plan Value Script sin prima en 43 estados.
Además del límite de $2,000 en el gasto de medicamentos, la IRA limita los copagos de Medicare para la mayoría de los productos de insulina a no más de $35 al mes y permite que Medicare negocie directamente los precios de algunos de los medicamentos más caros directamente con las farmacéuticas.
También eliminará una de las características más frustrantes del beneficio de medicamentos, una brecha conocida como el “agujero de dona (doughnut hole)” que suspende la cobertura justo cuando las personas enfrentan crecientes costos de medicamentos, obligándolas a pagar el precio completo de las drogas de su plan de su bolsillo hasta que alcancen un umbral de gasto que cambia de un año a otro.
La ley también amplía la elegibilidad para los subsidios de “ayuda adicional” para aproximadamente 17 millones de personas de bajos ingresos en los planes de medicamentos de Medicare y aumenta el monto del subsidio. Las farmacéuticas deberán contribuir para ayudar a pagarlo.
A partir del 1 de enero, el beneficio de medicamentos rediseñado funcionará más como otras pólizas de seguro privado. La cobertura comienza después que los pacientes paguen un deducible, que no será mayor de $590 el próximo año. Algunos planes ofrecen un deducible menor o ninguno, o excluyen ciertos medicamentos, generalmente genéricos baratos, del deducible.
Después que los beneficiarios gasten $2,000 en deducibles y copagos, el resto de sus medicamentos de la Parte D serán gratuitos.
Eso se debe a que la IRA aumenta la parte de la factura asumida por las aseguradoras y las compañías farmacéuticas. La ley también intenta frenar futuros aumentos de precios de medicamentos al limitar los aumentos a la tasa de inflación al consumidor, que fue del 3.4% en 2023. Si los precios suben más rápido que la inflación, las farmacéuticas deben pagar a Medicare la diferencia.
“Antes del rediseño, la Parte D incentivaba los aumentos de precios de los medicamentos”, dijo Gina Upchurch, farmacéutica y directora ejecutiva de Senior PharmAssist, una organización sin fines de lucro en Durham, Carolina del Norte, que asesora a beneficiarios de Medicare. “La forma en que está diseñada ahora coloca más obligaciones financieras en los planes y los fabricantes, presionándolos para que ayuden a controlar los precios”.
Otra disposición de la ley permite a los beneficiarios pagar los medicamentos en un plan de pago a plazos, en lugar de tener que pagar una factura abultada en un corto período de tiempo.
Las aseguradoras deben hacer los cálculos y enviar una factura mensual a los titulares de pólizas, que se ajustará si se agregan o eliminan medicamentos.
Junto con los grandes cambios introducidos por la IRA, los beneficiarios de Medicare deben prepararse para las sorpresas inevitables que surgen cuando las aseguradoras revisan sus planes para un nuevo año. Además de aumentar las primas, las aseguradoras pueden eliminar medicamentos cubiertos y eliminar farmacias, médicos u otros servicios de las redes de proveedores que los beneficiarios deben usar.
Perder la oportunidad de cambiar de plan significa que la cobertura se renovará automáticamente, incluso si cuesta más o ya no cubre los medicamentos que el afiliado necesito o sus farmacias preferidas.
La mayoría de los beneficiarios no pueden realizar ningún cambio en sus planes, o pasar a otros por fuera del período de inscripción annual, a menos que los CMS les otorgue un “período de inscripción especial”.
Sin embargo, muchos no se toman el tiempo para comparar docenas de planes que pueden cubrir diferentes medicamentos a diferentes precios en diferentes farmacias, incluso cuando el esfuerzo podría ahorrarles dinero.
En 2021, solo el 18% de los inscritos en planes de medicamentos de Medicare Advantage y el 31% de los miembros de planes de medicamentos independientes compararon los beneficios y costos de su plan con los de los competidores, según encontraron investigadores de KFF.
Para obtener ayuda gratuita e imparcial para elegir un plan de medicamentos, los beneficiarios pueden comunicarse con el Programa de Asistencia Estatal de Seguros de Salud (SHIP) de su estado en shiphelp.org o en la línea de ayuda 1-877-839-2675.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
USE OUR CONTENTThis story can be republished for free (details).
Medicare Drug Plans Are Getting Better Next Year. Some Will Also Cost More.
When Pam McClure learned she’d save nearly $4,000 on her prescription drugs next year, she said, “it sounded too good to be true.” She and her husband are both retired and live on a “very strict” budget in central North Dakota.
By the end of this year, she will have spent almost $6,000 for her medications, including a drug to control her diabetes.
McClure, 70, is one of about 3.2 million people with Medicare prescription drug insurance whose out-of-pocket medication costs will be capped at $2,000 in 2025 because of the Biden administration’s 2022 Inflation Reduction Act, according to an Avalere/AARP study.
“It’s wonderful — oh my gosh. We would actually be able to live,” McClure said. “I might be able to afford fresh fruit in the wintertime.”
The IRA, a climate and health care law that President Joe Biden and Vice President Kamala Harris promote on the campaign trail as one of their administration’s greatest accomplishments, radically redesigned Medicare’s drug benefit, called Part D, which serves about 53 million people 65 and older or with disabilities. The administration estimates that about 18.7 million people will save about $7.4 billion next year alone due to the cap on out-of-pocket spending and less publicized changes.
The annual enrollment period for Medicare beneficiaries to renew or switch drug coverage or to choose a Medicare Advantage plan began Oct. 15 and runs through Dec. 7. Medicare Advantage is the commercial alternative to traditional government-run Medicare and covers medical care and often prescription drugs. Medicare’s stand-alone drug plans, which cover medicines typically taken at home, are also administered by private insurance companies.
“We always encourage beneficiaries to really look at the plans and choose the best option for them,” Chiquita Brooks-LaSure, who heads the Centers for Medicare & Medicaid Services, told KFF Health News. “And this year in particular it’s important to do that because the benefit has changed so much.”
Improvements to Medicare drug coverage required by the IRA are the most sweeping changes since Congress added the benefit in 2003, but most voters don’t know about them, KFF surveys have found. And some beneficiaries may be surprised by a downside: premium increases for some plans.
CMS said Sept. 27 that nationwide the average Medicare drug plan premium fell about $1.63 a month — about 4% — from last year. “People enrolled in a Medicare Part D plan will continue to see stable premiums and will have ample choices of affordable Part D plans,” CMS said in a statement.
However, an analysis by KFF, a health information nonprofit that includes KFF Health News, found that “many insurers are increasing premiums” and that large insurers including UnitedHealthcare and Aetna also reduced the number of plans they offer.
Many Part D insurers’ initial 2025 premium proposals were even higher. To cushion the price shock, the Biden administration created what it calls a demonstration program to pay insurers $15 extra a month per beneficiary if they agreed to limit premium increases to no more than $35.
“In the absence of this demonstration, premium increases would certainly have been larger,” Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, wrote in her Oct. 3 analysis.
Nearly every Part D insurer agreed to the arrangement. Republicans have criticized it, questioning CMS’ authority to make the extra payments and calling them a political ploy in an election year. CMS officials say the government has taken similar measures when implementing other Medicare changes, including under President George W. Bush, a Republican.
In California, for example, Wellcare’s popular Value Script plan went from 40 cents a month to $17.40. The Value Script plan in New York went from $3.70 a month to $38.70, a more than tenfold hike — and precisely a $35 increase.
Cubanski identified eight plans in California that raised their premiums exactly $35 a month. KFF Health News found that premiums went up for at least 70% of drug plans offered in California, Texas, and New York and for about half of plans in Florida and Pennsylvania — the five states with the most Medicare beneficiaries.
Spokespeople for Wellcare and its parent company, Centene Corp., did not respond to requests for comment. In a statement this month, Centene’s senior vice president of clinical and specialty services, Sarah Baiocchi, said Wellcare would offer the Value Script plan with no premium in 43 states.
In addition to the $2,000 drug spending limit, the IRA caps Medicare copayments for most insulin products at no more than $35 a month and allows Medicare to negotiate prices of some of the most expensive drugs directly with pharmaceutical companies.
It will also eliminate one of the drug benefit’s most frustrating features, a gap known as the “donut hole,” which suspends coverage just as people face growing drug costs, forcing them to pay the plan’s full price for drugs out-of-pocket until they reach a spending threshold that changes from year to year.
The law also expands eligibility for “extra help” subsidies for about 17 million low-income people in Medicare drug plans and increases the amount of the subsidy. Drug companies will be required to chip in to help pay for it.
Starting Jan. 1, the redesigned drug benefit will operate more like other private insurance policies. Coverage begins after patients pay a deductible, which will be no more than $590 next year. Some plans offer a smaller or no deductible, or exclude certain drugs, usually inexpensive generics, from the deductible.
After beneficiaries spend $2,000 on deductibles and copayments, the rest of their Part D drugs are free.
That’s because the IRA raises the share of the bill picked up by insurers and pharmaceutical companies. The law also attempts to tamp down future drug price hikes by limiting increases to the consumer price inflation rate, which was 3.4% in 2023. If prices rise faster than inflation, drugmakers have to pay Medicare the difference.
“Before the redesign, Part D incentivized drug price increases,” said Gina Upchurch, a pharmacist and the executive director of Senior PharmAssist, a Durham, North Carolina, nonprofit that counsels Medicare beneficiaries. “The way it is designed now places more financial obligations on the plans and manufacturers, pressuring them to help control prices.”
Another provision of the law allows beneficiaries to pay for drugs on an installment plan, instead of having to pay a hefty bill over a short period of time. Insurers are supposed to do the math and send policyholders a monthly bill, which will be adjusted if drugs are added or dropped.
Along with big changes brought by the IRA, Medicare beneficiaries should prepare for the inevitable surprises that come when insurers revise their plans for a new year. In addition to raising premiums, insurers can drop covered drugs and eliminate pharmacies, doctors, or other services from the provider networks beneficiaries must use.
Missing the opportunity to switch plans means coverage will renew automatically, even if it costs more or no longer covers needed drugs or preferred pharmacies. Most beneficiaries are locked into Medicare drug and Advantage plans for the year unless CMS gives them a “special enrollment period.”
“We do have a system that is run through private health plans,” CMS chief Brooks-LaSure said. But she noted that beneficiaries “have the ability to change their plans.”
But many don’t take the time to compare dozens of plans that can cover different drugs at different prices from different pharmacies — even when the effort could save them money. In 2021, only 18% of Medicare Advantage drug plan enrollees and 31% of stand-alone drug plan members checked their plan’s benefits and costs against competitors’, KFF researchers found.
For free, unbiased help selecting drug coverage, contact the State Health Insurance Assistance Program at shiphelp.org or 1-877-839-2675.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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KFF Health News' 'What the Health?': Yet Another Promise for Long-Term Care Coverage
As part of a media blitz aimed at women voters, Vice President Kamala Harris this week rolled out a plan for Medicare to provide in-home long-term care services. It’s popular, particularly for families struggling to care for both young children and older relatives, but its enormous expense has prevented similar plans from being implemented for decades.
Meanwhile, President Joe Biden called out former President Donald Trump by name for having “led the onslaught of lies” about the federal efforts to help people affected by hurricanes Helene and Milton. Even some Republican officials say the misinformation about hurricane relief efforts is threatening public health.
This week’s panelists are Julie Rovner of KFF Health News, Shefali Luthra of The 19th, Jessie Hellmann of CQ Roll Call, and Joanne Kenen of the Johns Hopkins schools of public health and nursing and Politico.
Panelists Jessie Hellmann CQ Roll Call @jessiehellmann Read Jessie's stories. Joanne Kenen Johns Hopkins University and Politico @JoanneKenen Read Joanne's stories. Shefali Luthra The 19th @shefalil Read Shefali's stories.Among the takeaways from this week’s episode:
- Vice President Kamala Harris’ plan to expand Medicare to cover more long-term care is popular but not new, and in the past has proved prohibitively expensive.
- Former President Donald Trump has abandoned support for a drug price policy he pursued during his first term. The idea, which would lower drug prices in the U.S. to their levels in other industrialized countries, is vehemently opposed by the drug industry, raising the question of whether Trump is softening his hard line on the issue.
- Abortion continues to be the biggest health policy issue of 2024, as Republican candidates — in what seems to be a replay of 2022 — try to distance themselves from their support of abortion bans and other limits. Voters continue to favor reproductive rights, which creates a brand problem for the GOP. Trump’s going back and forth on his abortion positions is an exception to the tack other candidates have taken.
- The Supreme Court returned from its summer break and immediately declined to hear two abortion-related cases. One case pits Texas’ near-total abortion ban against a federal law that requires emergency abortions to be performed in certain cases. The other challenges a ruling earlier this year from the Alabama Supreme Court finding that embryos frozen for in vitro fertilization have the same legal rights as born humans.
- The 2024 KFF annual employer health benefits survey, released this week, showed a roughly 7% increase in premiums, with average family premiums now topping $25,000 per year. And that’s with most employers not covering two popular but expensive medical interventions: GLP-1 drugs for weight loss and IVF.
Also this week, excerpts from a KFF lunch with “Shark Tank” panelist and generic drug discounter Mark Cuban, who has been consulting with the Harris campaign about health care issues.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week they think you should read, too:
Julie Rovner: KFF Health News’ “A Boy’s Bicycling Death Haunts a Black Neighborhood. 35 Years Later, There’s Still No Sidewalk,” by Renuka Rayasam and Fred Clasen-Kelly.
Shefali Luthra: The 19th’s “Arizona’s Ballot Measure Could Shift the Narrative on Latinas and Abortion,” by Mel Leonor Barclay.
Jessie Hellmann: The Assembly’s “Helene Left Some NC Elder-Care Homes Without Power,” by Carli Brosseau.
Joanne Kenen: The New York Times’ “Her Face Was Unrecognizable After an Explosion. A Placenta Restored It,” by Kate Morgan.
Also mentioned on this week’s podcast:
- The New York Times’ “Biden Accuses Trump of ‘Outright Lies’ About Hurricane Response,” by Michael D. Shear.
- The Miami Herald’s “Florida Threatens To Prosecute TV Stations Over Abortion Ad. FCC Head Calls It ‘Dangerous,’” by Claire Healy and Ana Ceballos.
- KFF’s “2024 Employer Health Benefits Survey.”
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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Montana Looks To Fast-Track Medicaid Access for Older Applicants
Montana lawmakers are looking to fast-track Medicaid coverage for older adults who need help with daily life. LISTEN here:
Montana is looking to fast-track Medicaid access for older adults who need help to stay in their homes or towns.
Medicaid, the joint federal-state health care program for low-income Americans, opens the door to services such as paying for help to prepare meals or shower safely. But applying for and obtaining that coverage can take weeks or months, leaving aging people in a dangerous limbo: too vulnerable to live at home without assistance, but too healthy to merit a hospital or nursing home bed.
Montana lawmakers drafted a bill for the legislative session that begins in January that would create a shortcut to that care. The Children, Families, Health, and Human Services Interim Committee’s proposal would allow older people and those with a physical disability who are likely eligible for Medicaid to start receiving in-home and community-based care while awaiting final approval.
The goal of presumptive eligibility is to avoid delays in providing stabilizing care outside of medical facilities. Supporters of the plan say local care is also a lot less expensive than hospital or nursing home care.
Montana would join at least 11 states that have presumptive eligibility for seniors and people with disabilities to access in-home care, according to AARP. Washington state began expediting Medicaid coverage in 2023 for people recently discharged from a hospital and plans to expand coverage further. Rhode Island authorizes such benefits to new long-term care applicants. And a law signed last winter in New Jersey means seniors there will have similar access.
People who are hospitalized or checked into a nursing home can struggle to find the middle-ground option for care they need.
Katy Mack, a spokesperson for the Montana Hospital Association, said bottlenecks in the process are difficult for patients, long-term care providers, and hospitals.
“Many elderly patients do ‘get stuck’ in hospitals waiting for transfer to a more appropriate level of care,” Mack said in an email. “This is due to a variety of issues, including staffing, bed availability, and appropriate payments from the patient’s source of health coverage.”
Tyler Amundson, executive director of Big Sky Senior Services, a nonprofit that helps seniors stay in their home, said in one case, a couple without the support they needed ended up in the hospital dozens of times over two months.
“There are a lot of seniors in our community struggling,” Amundson said. “They’ll go home from a hospital with just enough care to get by for a little while.”
The nation’s pool of older Americans is getting bigger. With age comes more medical complications. People 65 or older have the highest rate of preventable hospitalizations, and medical emergencies risk worse health outcomes.
Rising health care costs are fueling anxiety among tens of millions of seniors, with 1 in 10 living below the federal poverty level. Older adults are struggling to pay the combined cost of housing and medical care, and some become homeless.
For years, states have had the option through the Affordable Care Act to allow qualified hospitals to extend presumptive eligibility to some adults based on their income, on top of the opportunity that most states give pregnant women and children. But in states such as Montana, people 65 and older haven’t been included. States need a federal waiver to expand who qualifies for that early access.
Alice Burns, who researches Medicaid issues at KFF, a health information nonprofit that includes KFF Health News, said widening presumptive eligibility for in-home and community-based care gained momentum during the covid-19 pandemic.
“It’s easy to understand why,” Burns said. “When we had the fatality rates in nursing facilities that we did, it was like, OK, we cannot send these people to the nursing facilities unnecessarily.”
The Montana proposal would, after state training, allow tribal entities, area agencies on aging, and hospitals, among others, to screen patients for presumptive eligibility. Approved patients would begin receiving services while state health officials review their applications.
The draft bill spells out some covered services, such as meal delivery and in-home medical equipment. Lawmakers noted it’s not clear if the proposal would help people move into long-term care, such as assisted living facilities, which offer daily support rather than medical treatment.
Montana officials don’t have an estimate for how much the temporary coverage would cost. Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services, declined to comment on the proposal.
Mike White is a co-owner of Caslen Living Centers, which has six small assisted living facilities across central and southwestern Montana. His company no longer accepts Medicaid applicants until their coverage is final, and White said it’s not alone. He said that process can take anywhere from three to six months due to cumbersome paperwork, which he said is too long for small businesses to go without pay.
State officials have said delays in Medicaid approval often stem from ongoing communication with applicants.
The state’s Medicaid program has gone through major upheaval in the past year as states nationwide reviewed eligibility for everyone on the program. Montana officials dropped more than 115,300 people from coverage in that process, according to the state’s final report. Those disenrollments continued as nonprofits and patients alike cited problems in the state’s process, including delays in application processing and access to help for other safety net services.
Now, state lawmakers predict a major political fight during the legislative session over whether to continue to allow expanded Medicaid access to people who earn up to 138% of the federal poverty level, or about $43,000 a year for a family of four.
State Rep. Mike Yakawich, the Billings Republican behind the presumptive eligibility proposal, said he wants to keep some of its language vague. He’s leaving room for negotiations and potential amendments during the legislative session and beyond.
“The focus is to keep people at home, and it’s still going to be a hard lift to get it past the session,” Yakawich said. “We can add more to it two years from now.”
Not everyone on the interim committee was on board.
Sen. Daniel Emrich, a Republican from Great Falls, voted against the policy, saying it sounded too much like a gamble for families.
“We run the risk of taking and providing a service that’s then going to be pulled out from under them,” Emrich said.
The counterargument is that such cases would be rare. Burns, with KFF, said there is no reliable data nationally to show how often people are denied Medicaid after being presumed eligible. Presumptive access to Medicaid in-home programs is relatively new. And, from hospital data for other patients, it’s difficult to know whether a person was denied Medicaid because they didn’t qualify or because they didn’t complete the paperwork after leaving the hospital.
“There’s all these places where the ball could get dropped,” Burns said.
She said the difference with measures like Montana’s is that support services follow patients in their daily life, making it less likely patients would fall off the radar.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Employers Haven’t a Clue How Their Drug Benefits Are Managed
Most employers have little idea what the pharmacy benefit managers they hire do with the money they exchange for the medications used by their employees, according to a KFF survey released Wednesday morning.
In KFF’s latest employer health benefits survey, company officials were asked how much of the rebates collected from drugmakers by pharmacy benefit managers, or PBMs, is returned to them. In recent years, the pharmaceutical industry has tried to deflect criticism of high drug prices by saying much of that income is siphoned off by the PBMs, companies that manage patients’ drug benefits on behalf of employers and health plans.
PBM leaders say they save companies and patients billions of dollars annually by obtaining rebates from drugmakers that they pass along to employers. Drugmakers, meanwhile, say they raise their list prices so high in order to afford the rebates that PBMs demand in exchange for placing the drugs on formularies that make them available to patients.
Leaders of the three largest PBMs — CVS Caremark, Optum RX and Express Scripts — all testified in Congress in July that 95% to 98% of the rebates they collect from drugmakers flow to employers.
For KFF’s survey of 2,142 randomly selected companies, officials from those with 500 or more employees were asked how much of the rebates negotiated by PBMs returned to the company as savings. About 19% said they received most of the rebates, 27% said some, and 16% said little. Thirty-seven percent of the respondents didn’t know.
While a larger percentage of officials from the largest companies said they got most or some of the rebates, the answers — and their contrast with the testimony of PBM leaders — reflect the confusion or ignorance of employers about what their drug benefit managers do, said survey leader Gary Claxton, a senior vice president at KFF, a health information nonprofit that includes KFF Health News.
“I don’t think they can ever know all the ways the money moves around because there are so many layers, between the wholesalers and the pharmacies and the manufacturers,” he said.
Critics say big PBMs — which are parts of conglomerates that include pharmacies, providers, and insurers — may conceal the size of their rebates by conducting negotiations through corporate-controlled rebate aggregators, or group purchasers, mostly based overseas in tax havens, that siphon off a percentage of the cash before it goes on the PBMs’ books.
PBMs also make money by encouraging or requiring patients to use affiliated specialty pharmacies, by skimping on payments to other pharmacies, and by collecting extra cash from drug companies through the federal 340B drug pricing program, which is aimed at lowering drug costs for low-income patients, said Antonio Ciaccia, CEO of 46brooklyn Research.
The KFF survey indicates how little employers understand the PBMs and their pricing policies. “Employers are generally frustrated by the lack of transparency into all the prices out there,” Claxton said. “They can’t actually know what’s true.”
Billionaire Mark Cuban started a company to undercut the PBMs by selling pharmaceuticals with transparent pricing policies. He tells Fortune 500 executives he meets, “You’re getting ripped off, you’re losing money because it’s not your core competency to understand how your PBM and health insurance contracts work,” Cuban told KFF Health News in an interview Tuesday.
Ciaccia, who has conducted PBM investigations for several states, said employers are not equipped to understand the behavior of the PBMs and often are surprised at how unregulated the PBM business is.
“You’d assume that employers want to pay less, that they would want to pay more attention,” he said. “But what I’ve learned is they are often underequipped, underresourced, and oftentimes not understanding the severity of the lack of oversight and accountability.”
Employers may assume the PBMs are acting in their best interest, but they don’t have a legal obligation to do so.
Prices can be all over the map, even those charged by the same PBM, Ciaccia said. In a Medicaid study he recently conducted, a PBM was billing employers anywhere from $2,000 to $8,000 for a month’s worth of imatinib, a cancer drug that can be bought as a generic for as little as $30.
PBM contracts often guarantee discounts of certain percentage points for generics and brand-name drugs. But the contracts then contain five pages of exclusions, and “no employer will know what they mean,” Ciaccia said. “That person doesn’t have enough information to have an informed opinion.”
The KFF survey found that companies’ annual premiums for coverage of individual employees had increased from an average of $7,739 in 2021 to $8,951 this year, and $22,221 to $25,572 for families. Among employers’ greatest concerns was how to cover increasingly popular weight loss drugs that list at $2,000 a month or more.
Only 18% of respondents said their companies covered drugs such as Wegovy for weight loss. The largest group of employers offering such coverage — 28% — was those with 5,000 or more employees.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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What’s New and What To Watch For in the Upcoming ACA Open Enrollment Period
It’s that time of year again: In most states, the Affordable Care Act’s annual open enrollment season for health plans begins Nov. 1 and lasts through Jan. 15.
Current enrollees who do not update their information or select an alternative will be automatically reenrolled in their current plan or, if that plan is no longer available, into a plan with similar coverage.
Last year marked a record enrollment of about 21 million people. This time around, consumers will find a few things have changed.
Don’t Fall for Advertising Scams
While some health plans offer small-dollar gift cards or other incentives to encourage participation in wellness efforts, they would not offer cash cards worth thousands of dollars a month to help with groceries, gas, or rent. Even so, social media and online sites are rife with such promises.
Such ads are among the avenues allegedly used by unscrupulous brokers who enroll or switch plans without the express permission of consumers, according to a lawsuit filed in Florida.
Also, be cautious about the websites you use to search for coverage.
Type “Obamacare” or “cheap health insurance” into a search engine and often what pops up first are sponsored private sector websites unaffiliated with the official state or federal government marketplaces for ACA coverage.
While they may try to look official, they are not. Many such sites offer various options, including non-ACA coverage with limited benefits, a “secret shopper” study found in 2023. Such non-ACA coverage would not qualify for federal subsidies to help consumers pay premiums.
The fine print on some websites says that consumers who provide personal information automatically consent to be contacted by sales agents via phone calls, emails, text messages, or automated systems with prerecorded messages.
When exploring plans, always start with the official federal marketplace’s website, healthcare.gov.
Even if you don’t live in one of the 29 states served by the federal marketplace, its website provides the link to your official enrollment site when you select your state, or the District of Columbia, from a drop-down list. The federal and state marketplaces also have call centers and other ways to get enrollment assistance. The “find local help” link on healthcare.gov, for example, gives consumers a choice of finding assisters or sales agents near them.
Is It Real Insurance?
Another concern: Regulators are seeing an increase in complaints from consumers about offers of health coverage requiring consumers to join a limited liability corporation, or otherwise attest they are working for a specific company. Indeed, at least two states — Maryland and Maine — have issued warnings, saying that instead of comprehensive ACA coverage, these are often non-ACA products, amounting to a hodgepodge of discount cards, for example, or limited-indemnity plans. This type of plan pays a flat-dollar amount — say, $50 for a doctor visit or $1,000 for a hospital stay — and is meant to buttress more comprehensive coverage, not replace it.
“Unlike major medical plans, some of these self-funded plans only cover preventive services such as a yearly check-up or annual health screening,” the warning from the Maine Bureau of Insurance says.
Premiums Might Be Higher … and Other New Things
Some insurers will lower premium rates for 2025, but many others are increasing them.
Although final numbers are still being crunched, experts estimate a median increase of 7% for premiums, according to an analysis by KFF, a health information nonprofit that includes KFF Health News. Most people who buy ACA coverage are eligible for a subsidy to help with the premiums, which is likely to offset much of the increase, although the higher cost means the government will be paying out more for those subsidies.
Rising health costs — including for hospital care and the new class of weight loss drugs — are contributing to the increase.
Some other changes this open season:
- People often referred to as “Dreamers” because they qualified for the Deferred Action for Childhood Arrivals — a federal program offering some protection to those brought to the country as children without proper immigration documentation — can now enroll in ACA coverage and are eligible for subsidies.
- Short-term plans, which are technically not ACA coverage and not subject to its benefit rules and preexisting benefit protections, can be issued for, at most, only four months of coverage, based on a Biden administration action that took effect with plans starting Sept. 1. It walks back a Trump administration rule that loosened requirements to allow insurers to offer coverage that ranged up to 364 days, and allowed insurers the option of renewing the policies for up to two additional years. Existing plans and those issued before Sept. 1 don’t fall under the new rules. But consumers who relied on the longer periods need to check their plans’ details and consider enrolling in an ACA plan instead to avoid a situation in which their short-term plan expires early or midyear, potentially leaving them unable to get coverage elsewhere for the remainder of the year.
The Sign-Up Process Might Take Longer, Too
Federal regulators this year wrestled with a growing number of complaints — 200,000 in the first six months alone — from consumers who were being enrolled into or switched from ACA plans without their express permission by agents seeking to gain commissions.
To thwart such efforts, they put new rules in place.
What does that mean for most consumers? If you are working with a new agent — one who wasn’t already listed on your ACA plan — you will likely need to get on a three-way call with the federal marketplace to confirm that you are, indeed, authorizing that agent to make changes to your policy for the coming year. Plan on this taking additional time. No one knows how busy the call lines will get during open enrollment.
You don’t need to use a broker to enroll. But sorting through the dozens of options on the marketplace is challenging, so most people do seek assistance. Consumers need to weigh not only the monthly premium cost, but also variations in deductibles and copayments for such things as doctor visits, hospitalization, and drugs.
Shop Around
Experts say another consideration when choosing a plan is to check whether its network includes the doctors and hospitals you typically see, as well as whether its formulary covers your prescription medications, and how much it charges for them.
To help with making comparisons, rules kicked in two years ago requiring insurers to include some “standardized plans” as options, which must all have the same deductibles, and costs for such things as doctor visits, emergency room care, and other consumer cost sharing.
Even so, many people have dozens of options available, which can be daunting.
But one piece of advice remains constant: Whether you are enrolling for the first time or have an existing plan, it’s always worth it to shop around. Even if you don’t change plans, you can make sure the one you have is still your best option.
In most states, consumers must enroll by Dec. 15 to get coverage that begins Jan. 1. Heads up in Idaho, where open enrollment starts earlier — Oct. 15 — but also ends sooner, closing on Dec. 15. In California, New Jersey, New York, Rhode Island, and the District of Columbia, residents can enroll through Jan. 31.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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KFF Health News' 'What the Health?': The Health of the Campaign
When it comes to health care, this year’s presidential campaign is increasingly a matter of which candidate voters choose to believe. Democrats, led by Vice President Kamala Harris, say Republicans want to further restrict reproductive rights and repeal the Affordable Care Act, pointing to their previous actions and claims. Meanwhile, Republicans, led by former President Donald Trump, insist they have no such plans.
Meanwhile, with open enrollment approaching for Medicare, the Biden administration dodges a political bullet, avoiding a sharp spike next year in Medicare prescription drug plan premiums.
This week’s panelists are Julie Rovner of KFF Health News, Alice Miranda Ollstein of Politico, Sandhya Raman of CQ Roll Call, and Anna Edney of Bloomberg News.
Panelists Anna Edney Bloomberg @annaedney Read Anna's stories. Alice Miranda Ollstein Politico @AliceOllstein Read Alice's stories. Sandhya Raman CQ Roll Call @SandhyaWrites Read Sandhya's stories.Among the takeaways from this week’s episode:
- This week, Sen. JD Vance of Ohio muddled his ticket’s stances on health policy during the vice presidential debate, including by downplaying the possibility of a national abortion ban. And Melania Trump, the former president’s wife, spoke out in support of abortion rights. Their comments seem designed to soothe voter concerns that former President Donald Trump could take actions to further block abortion access.
- Vance raised eyebrows with his debate-night claim that Trump “salvaged” the Affordable Care Act — when, in fact, the former president vowed to repeal the law and championed the GOP’s efforts to deliver on that promise. Meanwhile, Trump deflected questions from AARP about his plans for Medicare, replying, “What we have to do is make our country successful again.”
- On the Democratic side, Vice President Kamala Harris is campaigning on health, in particular by pushing out new ads highlighting the benefits of the ACA and Trump’s efforts to restrict abortion. Polls show health is a winning issue for Democrats and that the ACA is popular, especially its protections for those with preexisting conditions.
- Also in the news, the Centers for Medicare & Medicaid Services reported a slight dip in average Medicare drug plan premiums for next year. Coming in an annual report — out shortly before Election Day — it looks as though government subsidies cushioned changes to the system, sparing seniors from potentially paying in premiums what they may save under the new $2,000 annual out-of-pocket drug cost cap, for instance.
- And in abortion news, a judge struck down Georgia’s six-week abortion ban — but many providers have already left the state. And a new California law protects coverage for in vitro fertilization, including for LGBTQ+ couples.
Also this week, Rovner interviews KFF Health News’ Lauren Sausser, who reported and wrote the latest KFF Health News-Washington Post “Bill of the Month,” about a teen athlete whose needed surgery lacked a billing code. Do you have a confusing or outrageous medical bill you want to share? Tell us about it.
Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:
Julie Rovner: KFF Health News’ “Doctors Urging Conference Boycotts Over Abortion Bans Face Uphill Battle,” by Ronnie Cohen.
Anna Edney: Bloomberg News’ “A Free Drug Experiment Bypasses the US Health System’s Secret Fees,” by John Tozzi.
Alice Miranda Ollstein: The Wall Street Journal’s “Hospitals Hit With IV Fluid Shortage After Hurricane Helene,” by Joseph Walker and Peter Loftus.
Sandhya Raman: The Asheville Citizen Times’ “Without Water After Helene, Residents at Asheville Public Housing Complex Fear for Their Health,” by Jacob Biba.
Also mentioned on this week’s podcast:
- SisterSong v. State of Georgia: Superior Court of Fulton County decision.
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KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Harris Correct That Trump Fell Short on Promise To Negotiate Medicare Drug Prices
“Donald Trump said he was going to allow Medicare to negotiate drug prices. He never did. We did.”
Vice President Kamala Harris at the ABC News presidential debate, Sept. 10
Since Vice President Kamala Harris entered the presidential race, she and former President Donald Trump have sparred over their approaches to lowering prescription drug costs. Harris has described this as an important campaign promise that Trump made but didn’t deliver on.
“Donald Trump said he was going to allow Medicare to negotiate drug prices,” Harris said during the ABC News debate on Sept. 10 in Philadelphia. “He never did. We did.”
She previously told CNN that Trump’s promise to pursue such negotiations “never happened” during his administration.
During the 2016 presidential campaign, Trump repeatedly promised, if elected, to take steps to allow the government to negotiate drug prices. He never enacted such a policy in office. The Trump administration pursued smaller, temporary programs aimed at lowering drug costs.
However, experts say the effect of Trump’s moves fell far short of the expected effect of the Medicare drug price negotiation program included in President Joe Biden’s Inflation Reduction Act and of what Trump promised.
Medicare Drug Price Negotiation Policy, Explained
The Inflation Reduction Act — a sweeping climate and health care law Biden signed in August 2022 — included a measure authorizing the Centers for Medicare & Medicaid Services to negotiate Medicare prescription drug prices directly with pharmaceutical companies.
“The idea behind drug price negotiation is that Medicare can use its buying power to get a better price than what is currently being negotiated for these drugs,” according to Juliette Cubanski, deputy director of the Program on Medicare Policy at KFF, a health information nonprofit that includes KFF Health News.
Medicare covers more than 67 million Americans, giving it enormous potential influence over prices for U.S. drugs and medical services.
In August, CMS announced it had secured significant discounts on the list prices of 10 drugs because of its negotiations. Those discounts ranged from a 38% reduction for blood cancer medication Imbruvica on the low end to a 79% cut for diabetes drug Januvia on the high side. (List prices and the prices Medicare drug plans pay can differ.)
The new prices are expected to save Medicare $6 billion in the first year, with Medicare beneficiaries set to save an additional $1.5 billion in out-of-pocket costs, according to the White House.
Those new prices aren’t set to take effect until 2026 — though Biden and Harris have highlighted other aspects of the law that are bringing down drug costs sooner, such as a $35-a-month out-of-pocket price cap on insulin for Medicare enrollees and a $2,000 yearly out-of-pocket spending cap for Part D drugs effective in January. The Part D program covers most generic and brand-name outpatient prescription drugs.
CMS will start negotiating prices for the next group of drugs — 15 a year for the next two years — in early 2025, and those talks will continue annually at least through the end of the decade.
Trump’s Promises Versus His Actions
As a presidential candidate in 2016, Donald Trump pledged to pursue prescription drug price negotiation programs — and sometimes overstated such a policy’s power to cut prices.
During multiple campaign rallies and media interviews that year, Trump suggested allowing the government to negotiate drug prices directly with manufacturers would save $300 billion a year, a claim a fact-checker said was “absurd” then.
“The problem is, we don’t negotiate,” Trump said during an MSNBC town hall in Charleston, South Carolina, on Feb. 17, 2016. “We’re the largest drug buyer in the world. We don’t negotiate.” He went on to say: “If we negotiated the price of drugs, Joe, we’d save $300 billion a year.”
Similarly, at a Feb. 24, 2016, rally in Virginia Beach, Virginia, Trump reiterated his interest in making this change. “If you bid them out we’ll save $300 billion … and we don’t even do it. We’re going to do it.” The pharmaceutical industry would push back, he said, but he added: “Trust me I can do it.”
In office, however, Trump backed away from those promises, rejecting a bill spearheaded by then-House Speaker Nancy Pelosi (D-Calif.) to authorize such negotiations. The Democratic-led House ultimately passed that legislation, though the Republican-led Senate didn’t consider it.
“Pelosi and her Do Nothing Democrats drug pricing bill doesn’t do the trick,” Trump wrote on X, the social platform then known as Twitter.
Trump pursued smaller initiatives that sought to lower drug costs. One such program, the “most favored nation” model, tried to cap the cost of some Part B medications — those administered in a doctor’s office or hospital outpatient setting — at the lowest price paid in certain peer nations with a per capita GDP of at least 60% that of the United States.
“Medicare is the largest purchaser of drugs anywhere in the world by far,” Trump said in announcing the program. “We’re finally going to use that incredible power to achieve a fairer and lower price for everyone.”
The Trump campaign didn’t respond to an inquiry about prescription drug price negotiations or the most favored nation model.
The program would have started in January 2021 and lasted seven years. CMS officials estimated the government would save more than $85 billion on Part B spending. But some of those savings came from assumptions that Medicare beneficiaries would lose access to some Part B medications under the model, with some manufacturers unlikely to sell products at the lower, foreign prices.
Trump’s program never took effect. Amid lawsuits from several drug companies and industry groups, a federal judge stayed the plan in December 2020. The Biden administration scrapped it in 2022.
Even if the most favored nation model had been enacted, experts say it wouldn’t have come close to saving Americans or the government as much money as the IRA’s drug price negotiation provisions. A contemporaneous analysis of Trump’s proposal estimated that 7% of the 60 million Medicare beneficiaries in 2018 would have benefited.
More importantly, the most favored nation model did not authorize the government to negotiate prescription drug prices with manufacturers — the policy Trump promised to implement.
What Comes Next?
A recent KFF poll shows 85% of Americans, including more than three-quarters of Republicans, favor allowing Medicare to negotiate prices with drug companies.
And lowering drug costs continues to be a key issue for both campaigns, with Trump and Harris sparring over everything from the price of insulin to the impact of the Inflation Reduction Act on Medicare spending.
“I’ll lower the cost of insulin and prescription drugs for everyone with your support, not only our seniors,” Harris told supporters at an Aug. 16 campaign event in Raleigh, North Carolina, promising to extend the IRA’s price caps.
A Trump campaign spokesperson, meanwhile, previously told KFF Health News that the former president “will do everything possible to lower drug costs for Americans when he’s back in the White House, just like he accomplished in his first term.” She provided no specifics.
Trump, however, has also repeatedly promised to repeal parts of the Inflation Reduction Act — though he has never specifically mentioned the drug price negotiation provision — and to rescind unspent money. Congressional Republicans have spoken publicly about their intentions to roll back the drug price negotiation provision.
Even without legislative changes, the next president will have the opportunity to steer Medicare’s prescription drug price negotiation process.
“An administration that wants to be more lenient on drug companies might be more lax in the negotiations process,” said Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy. “Or the administration could perhaps be tougher than the Biden administration.”
Our Ruling
As a presidential candidate in 2016, Donald Trump promised to let the government negotiate prescription drug prices directly with pharmaceutical companies. As president, however, he instead tried to tie some U.S. drug prices to their costs in other countries. Drugmakers and industry groups sued, challenging the move, and courts blocked it.
Harris, therefore, is correct that Trump never was able to open Medicare up to drug negotiations despite his sweeping campaign promises.
We rate Harris’ claim True.
Our Sources:ABC News, “READ: Harris-Trump Presidential Debate Transcript,” Sept. 10, 2024
Axios, “Hill GOP Sets Sights on Scrapping Drug Price Talks,” Sept. 17, 2024
Centers for Medicare & Medicaid Services, “Trump Administration Announces Prescription Drug Payment Model To Put American Patients First,” Nov. 18, 2020
CNN, “READ: Harris and Walz’s Exclusive Joint Interview With CNN,” Aug. 30, 2024
Congress.gov, “H.R.3 – Elijah E. Cummings Lower Drug Costs Now Act,” accessed Sept. 17, 2024
Factbase, “Donald Trump Attends an MSNBC Town Hall in Charleston, South Carolina,” Feb. 17, 2016
Factbase, “Donald Trump in Pawleys Island, SC,” Feb. 19, 2016
Federal Register, “42 CFR Part 513,” Nov. 27, 2020
KFF, “A Status Report on Prescription Drug Policies and Proposals at the Start of the Biden Administration,” Feb. 11, 2021
KFF, “KFF Health Tracking Poll September 2024: Support for Reducing Prescription Drug Prices Remains High, Even As Awareness of IRA Provisions Lags,” Sept. 13, 2024
KFF, “Most People Are Unlikely To See Drug Cost Savings From President Trump’s ‘Most Favored Nation’ Proposal,” Aug. 27, 2020
KFF Health News, “5 Things To Know About the New Drug Pricing Negotiations,” Aug. 30, 2023
KFF Health News, “Harris Did Not Vote To ‘Cut Medicare,’ Despite Trump’s Claim,” Aug. 20, 2024
KFF Health News, “Trump Is Wrong in Claiming Full Credit for Lowering Insulin Prices,” July 18, 2024
Phone interview with Tricia Neuman, a senior vice president at KFF and the executive director of its Program on Medicare Policy, Sept. 13, 2024
Reuters, “Federal Judge Blocks Trump Administration Drug Pricing Rule,” Dec. 23, 2020
The Washington Post, “Trump’s Truly Absurd Claim He Would Save $300 Billion a Year on Prescription Drugs,” Feb. 18, 2016
The White House, “Remarks by President Trump at Signing of Executive Orders on Lowering Drug Prices” July 24, 2020
The White House, “Remarks by Vice President Harris at a Campaign Event in Raleigh, NC,” Aug. 16, 2024
X, then known as Twitter, “@RealDonaldTrump,” Nov. 22, 2019
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Vance-Walz Debate Highlighted Clear Health Policy Differences
Ohio Republican Sen. JD Vance and Minnesota Democratic Gov. Tim Walz met in an Oct. 1 vice presidential debate hosted by CBS News that was cordial and heavy on policy discussion — a striking change from the Sept. 10 debate between Vice President Kamala Harris and former President Donald Trump.
Vance and Walz acknowledged occasional agreement on policy points and respectfully addressed each other throughout the debate. But they were more pointed in their attacks on their rival’s running mates for challenges facing the country, including immigration and inflation.
The moderators, “CBS Evening News” anchor Norah O’Donnell and “Face the Nation” host Margaret Brennan, had said they planned to encourage candidates to fact-check each other, but sometimes clarified statements from the candidates.
After Vance made assertions about Springfield, Ohio, being overrun by “illegal immigrants,” Brennen pointed out that a large number of Haitian immigrants in Springfield, Ohio, are in the country legally. Vance objected and, eventually, CBS exercised the debate ground rule that allows the network to cut off the candidates’ microphones.
Most points were not fact checked in real time by the moderators. Vance resurfaced a recent health care theme – that as president, Donald Trump sought to save the Affordable Care Act – and acknowledged that he would support a national abortion ban.
Walz described how health care looked before the ACA compared to today. Vance offered details about Trump’s health care “concepts of a plan” – a reference to comments Trump made during the presidential debate that drew jeers and criticism for the former president, who for years said he had a plan to replace the ACA that never surfaced. Vance pointed to regulatory changes advanced during the Trump administration, used weedy phrases like “reinsurance regulations” and floated the idea of allowing states “to experiment a little bit on how to cover both the chronically ill but the non-chronically ill.”
Walz responded with a quick quip: “Here’s where being an old guy gives you some history. I was there at the creation of the ACA.” He said that before then insurers had more power to kick people off their plans. Then he detailed Trump’s efforts to undo the ACA as well as why the law’s preexisting condition protections were important.
“What Senator Vance just explained might be worse than a concept, because what he explained is pre Obamacare,” Walz said.
The candidates sparred on numerous topics. Our PolitiFact partners fact-checked the debate here and on their live blog.
The health-related excerpts follow.
The Affordable Care Act:
Vance: “Donald Trump could have destroyed the (Affordable Care Act). Instead, he worked in a bipartisan way to ensure that Americans had access to affordable care.”
As president, Trump worked to undermine and repeal the Affordable Care Act. He cut millions of dollars in federal funding for ACA outreach and navigators who help people sign up for health coverage. He enabled the sale of short-term health plans that don’t comply with the ACA consumer protections and allowed them to be sold for longer durations, which siphoned people away from the health law’s marketplaces.
Trump’s administration also backed state Medicaid waivers that imposed first-ever work requirements, reducing enrollment. He also ended insurance company subsidies that helped offset costs for low-income enrollees. He backed an unsuccessful repeal of the landmark 2010 health law and he backed the demise of a penalty imposed for failing to purchase health insurance.
Affordable Care Act enrollment declined by more than 2 million people during Trump’s presidency, and the number of uninsured Americans rose by 2.3 million, including 726,000 children, from 2016 to 2019, the U.S. Census Bureau reported; that includes three years of Trump’s presidency. The number of insured Americans rose again during the Biden administration.
Abortion and Reproductive Health:
Vance: “As I read the Minnesota law that (Walz) signed into law … it says that a doctor who presides over an abortion where the baby survives, the doctor is under no obligation to provide lifesaving care to a baby who survives a botched late-term abortion.”
Experts said cases in which a baby is born following an attempted abortion are rare. Less than 1% of abortions nationwide occur in the third trimester. And infanticide, the crime of killing a child within a year of its birth, is illegal in every state.
In May 2023, Walz, as Minnesota governor, signed legislation updating a state law for “infants who are born alive.” It said babies are “fully recognized” as human people and therefore, protected under state law. The change did not alter regulations that already require doctors to provide patients with appropriate care.
Previously, state law said, “All reasonable measures consistent with good medical practice, including the compilation of appropriate medical records, shall be taken by the responsible medical personnel to preserve the life and health of the born alive infant.” The law was updated to instead say medical personnel must “care for the infant who is born alive.”
When there are fetal anomalies that make it likely the fetus will die before or soon after birth, some parents decide to terminate the pregnancy by inducing childbirth so that they can hold their dying baby, Democratic Minnesota state Sen. Erin Maye Quade told PolitiFact in September.
This update to the law means infants who are “born alive” receive appropriate medical care dependent on the pregnancy’s circumstances, Maye Quade said.
Vance supported a national abortion ban before becoming Trump’s running mate.
CBS News moderator Margaret Brennan told Vance, “You have supported a federal ban on abortion after 15 weeks. In fact, you said, if someone can’t support legislation like that, quote, ‘you are making the United States the most barbaric pro-abortion regime anywhere in the entire world.’ My question is, why have you changed your position?”
Vance said that he “never supported a national ban” and, instead, previously supported setting “some minimum national standard.”
But in a January 2022 podcast interview, Vance said, “I certainly would like abortion to be illegal nationally.” In November, he told reporters that “we can’t give in to the idea that the federal Congress has no role in this matter.”
Since joining the Trump ticket, Vance has aligned his abortion rhetoric to match Trump’s and has said that abortion legislation should be left up to the states.
-Samantha Putterman of PolitiFact, on the live blog
A woman’s 2022 death in Georgia following the state passing its six-week abortion ban was deemed “preventable.”
Walz talked about the death of 28-year-old Amber Thurman, a Georgia woman who died after her care was delayed because of the state’s six-week abortion law. A judge called the law unconstitutional this week.
A Sept. 16 ProPublica report found that Thurman had taken abortion pills and encountered a rare complication. She sought care at Piedmont Henry Hospital in Atlanta to clear excess fetal tissue from her uterus, called a dilation and curettage, or D&C. The procedure is commonly used in abortions, and any doctor who violated Georgia’s law could be prosecuted and face up to a decade in prison.
Doctors waited 20 hours to finally operate, when Thurman’s organs were already failing, ProPublica reported. A panel of health experts tasked with examining pregnancy-related deaths to improve maternal health, deemed Thurman’s death “preventable,” according to the report, and said the hospital’s delay in performing the procedure had a “large” impact.
— Samantha Putterman of PolitiFact, on the live blog
What Project 2025 Says About Some Forms of Contraception, Fertility Treatments
Walz said that Project 2025 would “make it more difficult, if not impossible, to get contraception and limit access, if not eliminate access, to fertility treatments.”
Mostly False. The Project 2025 document doesn’t call for restricting standard contraceptive methods, such as birth control pills, but it defines emergency contraceptives as “abortifacients” and says they should be eliminated from the Affordable Care Act’s covered preventive services. Emergency contraception, such as Plan B and Ella, are not considered abortifacients, according to medical experts.
PolitiFact did not find any mention of in vitro fertilization throughout the document, or specific recommendations to curtail the practice in the U.S., but it contains language that supports legal rights for fetuses and embryos. Experts say this language can threaten family planning methods, including IVF and some forms of contraception.
— Samantha Putterman of PolitiFact, on the live blog
Walz: “Their Project 2025 is gonna have a registry of pregnancies.”
Project 2025 recommends that states submit more detailed abortion reporting to the federal government. It calls for more information about how and when abortions took place, as well as other statistics for miscarriages and stillbirths.
The manual does not mention, nor call for, a new federal agency tasked with registering pregnant women.
Fentanyl and Opioids:
Vance: “Kamala Harris let in fentanyl into our communities at record levels.”
Mostly False.
Illicit fentanyl seizures have been rising for years and reached record highs under Biden’s administration. In fiscal year 2015, for example, U.S. Customs and Border Protection seized 70 pounds of fentanyl. As of August 2024, agents have seized more than 19,000 pounds of fentanyl in fiscal year 2024, which ended in September.
But these are fentanyl seizures — not the amount of the narcotic being “let” into the United States.
Vance made this claim while criticizing Harris’ immigration policies. But fentanyl enters the U.S. through the southern border mainly at official ports of entry. It’s mostly smuggled in by U.S. citizens, according to the U.S. Sentencing Commission. Most illicit fentanyl in the U.S. comes from Mexico made with chemicals from Chinese labs.
Drug policy experts have said that the illicit fentanyl crisis began years before Biden’s administration and that Biden’s border policies are not to blame for overdose deaths.
Experts have also said Congress plays a role in reducing illicit fentanyl. Congressional funding for more vehicle scanners would help law enforcement seize more of the fentanyl that comes into the U.S. Harris has called for increased enforcement against illicit fentanyl use.
Walz: “And the good news on this is, is the last 12 months saw the largest decrease in opioid deaths in our nation’s history.”
Mostly True.
Overdose deaths involving opioids decreased from an estimated 84,181 in 2022 to 81,083 in 2023, based on the most recent provisional data from the Centers for Disease Control and Prevention. This decrease, which took place in the second half of 2023, followed a 67% increase in opioid-related deaths between 2017 and 2023.
The U.S. had an estimated 107,543 drug overdose deaths in 2023 — a 3% decrease from the 111,029 deaths estimated in 2022. This is the first annual decrease in overall drug overdose deaths since 2018. Nevertheless, the opioid death toll remains much higher than just a few years ago, according to KFF.
More Health-Related Comments:
Vance Said ‘Hospitals Are Overwhelmed.’ Local Officials Disagree.
We asked health officials ahead of the debate what they thought about Vance’s claims about Springfield’s emergency rooms being overwhelmed.
“This claim is not accurate,” said Chris Cook, health commissioner for Springfield’s Clark County.
Comparison data from the Centers for Medicare and Medicaid Services tracks how many patients are “left without being seen” as part of its effort to characterize whether emergency departments are able to handle their patient loads. High percentages usually signal that the facility doesn’t have the staff or resources to provide timely and effective emergency room care.
Cook said that the full-service hospital, Mercy Health Springfield Regional Medical Center, reports its emergency department is at or better than industry standard when it comes to this metric.
In July 2024, 3% of Mercy Health’s patients were counted in the “left-without-being-seen” category — the same level as both the state and national average for high-volume hospitals. In July 2019, Mercy Health tallied 2% of patients who “left without being seen.” That year, the state and national averages were 1% and 2%, respectively. Another Centers for Medicare and Medicaid Services 2024 datapoint shows Mercy Health patients spent less time in the emergency department per visit on average — 152 minutes — compared with state and national figures: 183 minutes and 211 minutes, respectively. Even so, Springfield Regional Medical Center’s Jennifer Robinson noted that Mercy Health has seen high utilization of women’s health, emergency, and primary care services.
— Stephanie Armour, Holly Hacker, and Stephanie Stapleton of KFF Health News, on the live blog
Minnesota’s Paid Leave Takes Effect in 2026
Walz signed paid family leave into law in 2023 and it will take effect in 2026.
The law will provide employees up to 12 weeks of paid medical leave and up to 12 weeks of paid family leave, which includes bonding with a child, caring for a family member, supporting survivors of domestic violence and sexual assault, and supporting active-duty deployments. A maximum 20 weeks are available in a benefit year if someone takes both medical and family leave.
Minnesota used a projected budget surplus to jump-start the program; funding will then shift to a payroll tax split between employers and workers.
— Amy Sherman of Politifact, on the live blog
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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Amid Medicaid ‘Unwinding,’ Many States Wind Up Expanding
It was expected that the past year and a half would be a fraught time for Medicaid, the workhorse of the nation’s health system, which covers more people than any other government health insurance program.
In April 2023, states resumed screening people for Medicaid eligibility and terminating coverage for those they said no longer qualified or failed to renew, which had been prohibited under pandemic-era protections. Many health advocates feared the uninsured rate, which had just hit historic lows, would resurge.
But while more than 25 million Americans have lost Medicaid coverage during the Medicaid “unwinding,” many also gained coverage as more than a dozen states expanded health coverage for lower-income people, including children, pregnant women and incarcerated people. And early data shows the uninsured rate has risen only modestly.
The expansions will mitigate the effects of the unwinding, though it’s too early to know by how much.
“The pandemic was destructive and concerning and clearly demonstrated that Medicaid is so crucially important for our national safety net,” said Jennifer Babcock, senior vice president for Medicaid policy at the Association for Community Affiliated Plans, a trade group representing nonprofit health insurers that cover people on Medicaid. “These expansions are incredibly meaningful.”
The biggest expansion occurred in December, when North Carolina joined 39 other states and D.C. in widening Medicaid eligibility to include adults with incomes up to 138 percent of the federal poverty level, or $20,783 for an individual. More than 500,000 North Carolinians gained coverage.
Other expansions since spring 2023 include:
- South Dakota, like North Carolina, expanded Medicaid coverage under the Affordable Care Act last year. About 22,000 people enrolled in the first eight months.
- In July, Oregon launched a Medicaid-like coverage option for those who earn too much to qualify for Medicaid under federal limits. More than 50,000 people have enrolled so far, Oregon officials say.
- In January, a new federal law required states to allow children under the age of 19 to stay covered under Medicaid or the related Children’s Health Insurance Program for at least a year after signing up. Several are going beyond that: New Mexico and Washington, for example, allow children to stay covered up to age 6. California passed legislation to expand continuous eligibility for children up to age 4 but has not yet implemented the policy.
- Three states widened income eligibility for children to qualify for Medicaid: Arizona, Maine and North Dakota.
- This year, Utah began offering a Medicaid-like coverage option for children regardless of immigration status, though the program is capped at about 2,000 children.
- Several states expanded coverage for pregnant women, including Alabama and Maryland, which expanded eligibility to pregnant residents regardless of immigration status. And with changes in Maine, Oregon and Vermont, 46 states and D.C. now offer one year of postpartum coverage.
- In June, five states — Illinois, Kentucky, Oregon, Utah and Vermont — received approval from the Biden administration to extend Medicaid coverage to incarcerated people up to 90 days before their release. Those states will join several others in offering that coverage.
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Benefit Trend: Employers Opt To Give Workers an Allowance for Coverage
Dave Lantz is no stranger to emergency department or doctor bills. With three kids in their teens and early 20s, “when someone gets sick or breaks an arm, all of a sudden you have thousand-dollar medical bills,” Lantz said.
The family’s health plan that he used to get as the assistant director of physical plant at Lycoming College, a small liberal arts school in central Pennsylvania, didn’t start to cover their costs until they had paid $5,600 in medical bills. The Lantzes were on the hook up to that annual threshold. The high-deductible plan wasn’t ideal for the family of five, but it was the only coverage option available to them.
Things are very different now. In mid-2022, the college ditched its group health plan and replaced it with a new type of plan — an individual coverage health reimbursement arrangement, or ICHRA.
Now Lantz gets a set amount from his employer every month that he puts toward a family plan on the individual insurance market. He opted for a zero-deductible plan with a richer level of coverage than the group plan. Though its $790 monthly premium is higher than the $411 he used to pay, he ends up saving money overall by not having to pay down that big deductible. Plus, he now has more control over his health spending.
“It’s nice to have the choice to balance the high deductible versus the higher premium,” Lantz said. Before, “it was tough to budget for that deductible.”
As health insurance costs continue to rise, employers are eyeing this type of health reimbursement arrangement to control their health care spending while still providing a benefit that workers value. Some consumer advocates are concerned the plans could result in skimpier, pricier coverage for certain consumers, especially sicker, older ones.
The plans allow employers to make tax-preferred contributions to employees to use to buy coverage on the individual market. Employers thus limit their financial exposure to rising health care costs. Everybody wins, say backers of the plans, which were established in 2019 as part of a group of proposals the Trump administration said would increase health insurance choice and competition.
“It’s a way to offer coverage to more diverse employee groups than ever before and set a budget that controls costs for the companies,” said Robin Paoli, executive director of the HRA Council, an advocacy group.
Some health insurance specialists say the plans aren’t necessarily a good option for consumers or the individual insurance market. Even though the rules prevent employers from offering this type of coverage to specific workers who may be sicker and more expensive to cover than others, employers with relatively unhealthy workforces may find the arrangements appealing. This, in turn, may drive up premiums in the individual market, according to an analysis by the University of Southern California-Brookings Schaeffer Initiative for Health Policy.
Plans sold on the individual market often have smaller provider networks and higher deductibles than employer-sponsored coverage. Premiums are often higher than for comparable group coverage. Workers, especially lower-wage ones, might be better off financially with premium tax credits and cost-sharing reductions to buy an Affordable Care Act marketplace plan, but using the work-based ICHRA benefit would disqualify them.
“From a worker perspective, the largest impact is that being offered affordable coverage by your employer makes you ineligible for marketplace subsidies,” said Matthew Fiedler, a senior fellow at the Brookings Institution who co-authored the analysis of the rule establishing the plans.
The plans are currently offered to only a tiny slice of workers: an estimated 500,000 of the roughly 165 million people with employer-sponsored coverage, according to the HRA Council. But interest is growing. The number of employers offering ICHRAs and an earlier type of plan, called qualified small-employer HRAs, increased 29% from 2023 to 2024, according to the council. And, although small employers have made up the bulk of adopters to date, larger employers with at least 50 workers are the fastest-growing cohort.
Individual market insurers like Oscar Health and Centene see opportunities to expand their footprint through the plans. Some venture capitalists are touting them as well.
“The [traditional group] health insurance cornerstone from 60 years ago has outlived its usefulness,” said Matt Miller, whose Headwater Ventures has invested in the ICHRA administrator Venteur. “The goal is to ensure people have coverage, detaching it from the employment construct and making it portable.”
Employers can offer this type of health reimbursement arrangement to some classes of employees and group plans to others based on characteristics such as geography, full-time vs. part-time status, or salaried vs. hourly pay.
Lycoming College wasn’t aiming to be on the cutting edge when it made this coverage switch. Faced with a 60% premium increase after some members had high claims, the school, which covers roughly 400 faculty and staff and their family members, needed to look at alternatives, said Kacy Hagan, its associate vice president for human resources and compliance.
In the end, they opted to offer ICHRA coverage to any employee who worked at least 30 hours a week.
In the first year of offering the new benefit, the college saved $1.4 million in health care costs over what they would have spent if they’d stayed with its group plan. Employees saved an average of $1,200 each in premiums.
“The finance folks really like it,” Hagan said. As for employees, “from a cost standpoint, people tend to be pretty happy with it, and people really like having a choice of plans,” she said. However, there have been issues with the plan’s administration. Some employees’ coverage was dropped and had to be reinstated, she said. Those problems have been largely resolved since they switched plan administrators this year.
This coverage arrangement can be complicated to manage. Instead of a company paying one group health plan premium, dozens of individual health insurers may need to be paid. And employees who’ve never shopped for a plan before need help figuring out what coverage works for them and signing up.
The complexity can be off-putting. This year, a number of companies that have tried this type of health reimbursement arrangement decided they’d rather go back to a group plan, said Tim Hebert, managing partner of Sage Benefit Advisors, based in Fort Collins, Colorado.
“They say, ‘Employees are all over the place in different plans, and they don’t feel like they’re being taken care of,’” Hebert said.
Vendors continue to crop up to help employers like Lycoming College and their workers manage their plans.
“If you just say, ‘Here’s $1,000,’ it’s extremely discombobulating and confusing,” said Jack Hooper, CEO of Take Command Health, which now administers the Lycoming ICHRA.
It’s unclear whether the plans will take off or remain a niche product.
“It’s a big disrupter, like 401(k)s,” said Mark Mixer, board chair of the HRA Council and CEO of HealthOne Alliance in Dalton, Georgia. Still, it’s not for everyone. “It’s simply another tool that employers should consider. When it fits, do it.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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