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Scrooge Economics: The GOP Assault On SNAP And Medicaid Will Devastate Millions

Scrooge Economics: The GOP Assault On SNAP And Medicaid Will Devastate Millions

If you’re like me, your mail and email inboxes are filled this holiday season with pleas for donations from charitable organizations that help people on the lower rungs of the economic ladder. Now more than ever they need our help because of the draconian cutbacks in funding contained in the legislation passed by the Republican Congress last July and signed into law by Donald Trump.

During the six-week government shutdown this fall, Democrats fought a worthy yet unsuccessful battle to renew the Biden-era’s increased Obamacare subsidies. Without them, millions of working people without employer-based coverage (the self-insured) won’t be able to afford their health insurance.

As of this writing, it seems unlikely the negotiations promised when the shutdown ended will succeed in reversing those cuts. Millions of people are expected to drop coverage next year because of the dramatic increase in their health insurance premiums.

Less attention on Medicaid/SNAP cuts

While those discussions are underway, few on Capitol Hill are talking about reversing the cuts to Medicaid and the Supplemental Nutrition Assistance Program (commonly known as food stamps), which won’t hit in full force until 2027. This was a strategic decision by the GOP to hide their full impact from voters until after the mid-term elections. Those cuts will affect far more people that the Obamacare premium increases.

Indeed, the Medicaid/SNAP cuts will be the biggest reductions in federal assistance for the poor in U.S. history. It’s already forced thousands of legal immigrants in the U.S. off of Medicaid. The Congressional Budget Office estimates it will eventually remove an estimated 7.5 million people from the program, mostly by setting up bureaucratic roadblocks to re-enrollment for people who already meet the law’s new work requirements.*

Those Medicaid cuts will account for three-fourths of the 10 million people expected to lose health care coverage over the next decade under the One Big Ugly Bill. Meanwhile, about 40 million people will receive smaller food subsidies unless states step in to help — an unlikely outcome in most areas of the country.

For anyone who cares about deficits, pay attention to the underlying math. The cuts to Medicaid and SNAP will reduce federal expenditures by about $1.1 trillion over the next decade. Extending the Obamacare subsidies would cost about $350 billion. The new and renewed tax cuts for corporations and the well-off will cost the Treasury about $4 trillion. Couldn’t they make do with just $2.5 trillion in tax cuts and leave the poor and self-insured alone?

Donald Trump and the GOP, meet Ebenezer Scrooge. You have a lot in common.

Cuts will affect everyone

These Medicaid/SNAP cuts aren’t going to affect just the poor and working class. They will hit everyone with employer-based coverage. Premiums for private coverage will rise even faster than now (six to seven percent on average for next year) due to the higher levels of uncompensated care given to the growing number of uninsured people who will be visiting the nation’s emergency rooms, where care is the most expensive.

It will also hit everyone who pays state and local taxes since states will be forced to pick up a higher share of the overall cost of Medicaid. The single biggest “revenue raiser” in the bill is a reduction in the tax that states are allowed to levy on health care providers. These provider taxes are used by states to pay for their share of the Medicaid program. They also increase the matching amount paid by the federal government. Every state but Alaska levies provider taxes, so this will be a big-time loss for almost every state in the country and their taxpayers.

Medicaid is the second largest expenditure in every state budget, just behind K-12 education. State and local officials, who must balance their budgets, will have just three options when faced with these draconian cuts. They can take money from other budgets like education (unlikely); they can raise taxes (a few blue states, maybe); or they can cut services (the most likely).

There are only two ways to cut services. They can eliminate non-emergency services like preventive screening, dental care and nascent programs to provide healthy food and shelter. These are precisely the kinds of services that prevent illnesses like cancers or tooth abscesses, which are far more costly to treat when left to fester. Cutting services is a penny-wise, pound-foolish alternative.

The other option is cutting Medicaid provider reimbursement rates, which are already lower than either Medicare or private insurance rates. Low physician payment rates are the main reason why only 70 percent of the doctors in the U.S. treat Medicaid patients, unlike the more than 95 percent who treat Medicare patients. Health care access will become immeasurably worse should states pursue this strategy.

“Things are going to get a lot worse"

Either way, the looming Medicaid cuts will have a major impact on health care systems across the country, which are usually the largest employer in every town, city and county. People with fewer SNAP benefits spend less at grocery stories.

A recent Commonwealth Fund study estimated state gross domestic products would fall by $154 billion by 2029, which is more than the federal government would save, and cost over 1.2 million people their jobs. State and local tax revenue would fall by $12 billion.

But the harshest impact will be on providers who are heavily dependent on Medicaid patients for most of their funding, which are urban safety net and rural hospitals. The GOP legislation set up a $10 billion-per-year fund for five years to help rural hospitals. But half its money will be evenly divided among the 50 states — a pittance compared to all the cuts coming down the pike. Moreover, it will do nothing for urban safety net hospitals, which are overwhelmingly located in Democratically-run cities.

The bottom line is that hospital systems and local physician groups dependent on Medicaid will face greater financial struggles, layoffs and closures. “Safety nets are struggling right now,” Dr. Erik Mikaitis, the CEO of Cook County Health, told a health care forum sponsored by Crain’s Chicago Business on Wednesday morning. The system gets 56% of its $5.14 billion budget through Medicaid. “Things are only going to get a lot worse.”




Stop The Gouging: A Bold Plan To Make American Health Care Truly 'Affordable'

Stop The Gouging: A Bold Plan To Make American Health Care Truly 'Affordable'

It happened so quickly you might have missed it. In early September, media outlets across the country reported alarming news for everyone on employer-based health insurance plans.

A national survey of 1,700 businesses that offer health insurance to their workers found that 2026 will bring the steepest increases in their medical costs in 15 years—6.7 percent, on top of a six percent rise in 2025. They blame higher hospital and drug prices, greater demand for care, and other factors. According to the consulting firm Mercer, which conducted the survey, much of that burden will be foisted onto employees in the form of higher premiums taken out of their paychecks and higher co-pays and deductibles when hospitalized, seeing a doctor, or filling a prescription.

This pain is hitting at a time when most Americans are struggling financially, and “affordability” is dominating political debate. President Donald Trump’s poll numbers are sinking because voters feel he has betrayed his campaign promise to bring down living costs. Democrats, meanwhile, swept off-year elections by laser-focusing on that vulnerability.

Yet neither party has managed to come up with a plan to address exploding health care costs for the 165 million Americans with employer-provided insurance. During their failed six-week government shutdown, Democrats in Congress put their political chips on a different health care cost crisis: the expiration of the Obamacare tax credits that Republicans refused to extend in their One Big [Ugly] Bill last summer.

Restoring those tax credits is certainly a worthy fight. More than seven million Americans face an average 26 percent increase in their premiums in 2026, according to KFF (formerly Kaiser Family Foundation). Some 5 million will likely drop coverage altogether, unraveling much of the gains made since passage of the Affordable Care Act in 2010. Another eight million will lose Medicaid coverage over the next decade because of cuts to that program in the OBBBA, according to the Congressional Budget Office. As I recently explained in The Washington Monthly, universal coverage is a necessary, though not sufficient, condition for addressing the long-term affordability crisis in health care.

But in terms of basic political arithmetic, the failure of both parties to offer voters a specific plan for dealing with rising employer-provided health care costs is hard to fathom. After all, 70 percent of working-age Americans get their health insurance from their employers, compared to 10 percent from Medicaid and under five percent from Obamacare. (The rest are either uninsured or have military or Medicare disability coverage.)

Employer-provided plans not only cover most working-age Americans and their families, but are also where the health care system’s inflation is worst. Thanks to cost control requirements in the Obama administration’s Affordable Care Act and other government measures, spending per enrollee in Medicare and Medicaid has risen far more slowly over the last 15 years than in employer-sponsored plans. The latter aren’t subject to such controls and are increasingly vulnerable to price gouging by provider and insurer conglomerates that enjoy geographic monopolies.

The rapid inflation in the prices paid to hospitals, doctors, labs, and other health care providers by employer-sponsored plans also contributes to the slow or stagnant real wage growth that most Americans have experienced for many years. Corporate revenues that might otherwise have gone to raises have instead been spent on the ever-rising costs that employer plans are compelled to absorb.

For a long time, most workers covered by these plans were only dimly aware of how these rising prices affected their standard of living because they rarely had to reach directly into their own pockets to pay them. But that is becoming less true as employers try to offset the ballooning costs by exposing their employees to ever-higher premiums, deductions, co-pays, and co-insurance. In recent years these out-of-pocket costs have on average been speeding ahead at a rate faster than inflation and workers’ wage gains.

Just as rising electric bills turned out to be the sleeper concern of voters in the 2025 off-year elections, so might higher employer-provided health care costs in the 2026 midterms. It would be political malpractice if Democrats did not offer the 165 million Americans with employer-provided coverage real relief from costs that are eating away at their paychecks and standard of living.

A three-part solution

In what follows, I sketch out the basics of a three-part plan that offers a practical and enduring solution to the health care affordability crisis.

First, the plan would place a reasonable cap on the percentage of income any individual or family must pay for health care annually, regardless of whether or how they are insured. This will radically reduce the financial toxicity visited on many insured persons when they get sick, and the scourge of new medical debt heaped on the un- and underinsured.

Second, the plan would require health care providers to charge the same price for the same service, regardless of a patient’s insurance status. This will save the system hundreds of billions of dollars annually by reducing administrative expenses and by bringing down the grossly inflated prices providers charge patients with employer-provided coverage––currently 2.5 times what they charge Medicare.

Finally, the plan would put all hospitals on a budget—a move that would end insurers’ prior authorization schemes and incentivize providers to keep people well and deliver the most effective and efficient care when they get sick.

This three-part reform plan will put the American health care system on a long-term path to controlling overall costs. It will also help employers’ bottom lines and increase the likelihood that more small businesses will be able to offer health insurance to their employees. Best of all, if accompanied by a mandate that employers share a portion of the savings with their employees, it will deliver immediate relief of between $1,500 and $4,000 to the typical working American family—a rebate, if you will, on the excessive health care expenses they have been unwittingly paying. That’s a benefit any self-respecting political candidate ought to be happy to run on.

One bold solution that many left-of-center Democratic candidates competing in next spring’s primaries will likely run on is Medicare for All. But in general elections, that program will run into the same political buzz saw that doomed the effort in Sen. Bernie Sanders’s Vermont, the only state that has tried to create a M4A model. Its Democratic governor concluded the level of taxation necessary to entirely replace employer contributions and reduce individual out-of-pocket expenses was prohibitive. Moreover, a single-payer health care system remains vulnerable to politically charged slogans like “you’ll lose what you have.” Despite the staggering growth in costs, most businesses, unions, and employees want to keep employer-based coverage.

Other Democrats, meanwhile, are already fashioning long lists of health care system changes they hope to enact should they regain Congress and the White House in 2029. Those include curbing provider and insurer consolidation through rigorous application of antitrust law; lowering the Medicare eligibility age to 60; extending the government’s price negotiations to more drugs; prohibiting drug advertising on television; cracking down on pharmacy benefit managers; allowing greater use of physician and nurse assistants; more funding for fighting substance abuse and treating mental health; and more. Few will read this small-bore, incrementalist agenda, and even fewer will understand how it saves them money.

What the Democratic Party and health care reformers need to address directly is affordability, the main issue bedeviling the American people. The reforms needed to achieve affordability must be few in number, easy to understand, and provide real relief. As former Labor Secretary Robert Reich recently noted, people are not persuaded by a “‘10-point plan’ with refundable tax credits that no one understands.”

To that end, I propose that every Democratic candidate looking for a popular, easy-to-sell health care agenda unite around these three simple reforms.

1. A firm cap on all out-of-pocket expenses

All payers, whether private or public, must restructure their health plans so that no individual or family spends more than 8 percent of their annual income on health care. This cap covers all premiums, co-premiums, deductibles, co-pays, and Medicare payroll taxes and Part B premiums. A hard cap will sharply reduce the number of people accruing new medical debt. The medical debt crisis has left at least 20 million adults with either unpaid bills or long-term debts (some estimates are as high as 36 percent of all U.S. households). This forces millions of people into credit card debt, the arms of predatory lenders, or bankruptcy. It forces them to cut back spending, eliminate “frills” like home repairs and family vacations, and skip payments on other bills.

A firm cap on out-of-pocket spending will substantially reduce the unseemly sight of Americans, alone in the developed world, launching GoFundMe pages to pay their medical bills. It will also finally make the U.S. health insurance system fair because it spreads the financing of high-cost patients across all plan members without unduly burdening the sick. This is, after all, what insurance is supposed to be about.

All government programs and the individual market under Obamacare will also be governed by this cap. In the latter case, it will replace its current complicated subsidy formula. There is a precedent for this principle: The Biden administration’s enhanced subsidies for exchange-purchased plans included an 8.5 percent cap on individual premiums.

2. One price for all

America must adopt a single pricing system under which each provider charges all payers the same amount for the same service or product. This will sharply lower prices for private plans, which paid on average 2.5 times more than Medicare and Medicaid in 2022, according to a Rand survey. This in turn will provide substantial premium relief for both employers and workers.

The U.S. is the only country in the world that has an optional private insurance market for the working-age population with no government-mandated mechanism for controlling prices or premiums. (As noted above, those are slated to rise by nearly seven percent next year.) Multiple payers in that private insurance market create multiple prices that are largely determined by the relative market power of providers and insurers, which have been combining into geographic monopolies that extract ever-higher payments from employers.

As a result, U.S. hospitals and physicians’ offices administer the most confusing and expensive billing systems in the world. Some providers have as many as a dozen different prices for the same service: one for traditional Medicare, one for Medicaid, and one for each insurer in their service territory—each of which negotiates different rates for its different plans, including privately managed Medicare Advantage and Medicaid. Then there’s the rack rate for anyone who walks in off the street.

The cost estimates for administering this complex system range into the hundreds of billions of dollars a year. I estimate the administrative savings alone from simplified single-pricing could save employers and employees at least $100 billion a year in reduced premiums.

Prices would instead be determined by a process like the one Medicare has used for decades to set the amount doctors and hospitals receive for treating patients with specific conditions (with individual hospitals having some pricing flexibility as long as they charge all patients the same—see next section). In practice, that would mean raising Medicare and Medicaid rates while dropping commercial rates, thereby creating a single price schedule sufficient to meet the overall financial needs of the system. The exact amount of savings would depend on how much government program prices would have to rise to accommodate the economic needs and political power of providers. But the savings to employers and covered employees would be enormous, likely reducing premiums by hundreds of billions of dollars annually in addition to the $100 billion in administrative savings.

Another benefit of single pricing is transparency for consumers. Not many medical services are shoppable. No one experiencing what they think is a heart attack rushes to their computer before the ambulance arrives to find out who has the cheapest ER prices. Indeed, a recent study by the Health Care Cost Institute estimated that only 12 percent of 2017 medical expenditures, excluding prescription drugs, were either delayable or discretionary, and thus shoppable.

But greater competition in this limited set of services can help keep prices down. Unfortunately, current transparency laws have proven largely unworkable for consumers hoping to shop around for the cheapest alternative for, say, an MRI scan on that troublesome knee, or a routine colonoscopy. Most providers, given the multiple prices they must post, have created disclosure websites that are about as easy to navigate as a health insurance policy. Requiring every provider to list a single price, especially if linked to the federal government’s existing quality ratings, will foster competition previously unknown in the health care sector.

Finally, single pricing will remove the single biggest roadblock to Medicaid patients finding providers willing to take their insurance. The Medicaid Payment Advisory Commission estimates only 70 percent of physicians are willing to take new Medicaid patients compared to more than 95 percent who welcome new Medicare patients. Why? Low Medicaid prices. If every provider has to charge every payer the same price, this problem largely goes away except in many rural or economically depressed areas where everyone faces a provider shortage.

3. Put providers on a budget

Serious problems can arise after moving to a single-price system, as Maryland, the only state that has one, discovered over a decade ago. Hospitals there began to game the system by increasing unnecessary surgeries, tests, and procedures.

Maryland’s solution was to require that hospitals and hospital systems, which collect a third of all health care spending, adhere to an annual budget no matter what price they set on individual services. The state’s regulator, the Health Services Cost Review Commission, also sets limits on how much those budgets can grow each year after accounting for changes in demographics, best practices, and technology. Providers are guaranteed their annual budgets. If an individual service is used more or less than anticipated, the price for that service can be adjusted up or down for all patients, but hospitals may not exceed their budgets.

Requiring providers to adopt these so-called “global” budgets that grow more slowly than the rest of the economy creates a financial incentive for eliminating wasteful care, and frees up resources to boost primary and preventative care. Hospitals on a budget earn more money if they don’t have to provide as much care for the sick, meaning that they’re incentivized to keep people healthy while generating the best health outcomes at the lowest possible price for their patients when they do get sic

Yet neither party has managed to come up with a plan to address exploding health care costs for the 165 million Americans with employer-provided insurance. During their failed six-week government shutdown, Democrats in Congress put their political chips on a different health care cost crisis: the expiration of the Obamacare tax credits that Republicans refused to extend in their One Big [Ugly] Bill last summer.

Restoring those tax credits is certainly a worthy fight. More than seven million Americans face an average 26 percent increase in their premiums in 2026, according to KFF (formerly Kaiser Family Foundation). Some five million will likely drop coverage altogether, unraveling much of the gains made since passage of the Affordable Care Act in 2010. Another 8 million will lose Medicaid coverage over the next decade because of cuts to that program in the OBBBA, according to the Congressional Budget Office. As I recently explained in the Washington Monthly, universal coverage is a necessary, though not sufficient, condition for addressing the long-term affordability crisis in health care.

But in terms of basic political arithmetic, the failure of both parties to offer voters a specific plan for dealing with rising employer-provided health care costs is hard to fathom. After all, 70 percent of working-age Americans get their health insurance from their employers, compared to 10 percent from Medicaid and under 5 percent from Obamacare. (The rest are either uninsured or have military or Medicare disability coverage.)

Tax Reform Is Key

These three reforms work best if adopted in tandem. Each cannot succeed on its own. But if adopted together as part of new federal legislation, these reforms could put the U.S. health care system on a glidepath to financial sustainability.

Making them work will require significant federal expenditures. How much, and how to pay for it, is a difficult but solvable question.

Phillip Longman, senior editor at the Washington Monthly, has long argued for a single- price system that would reduce what self-insured businesses and private insurers pay by 60 percent, matching the prices that Medicare currently pays. If this were possible, no federal funds would be needed to finance a single price system. Alas, I don’t believe it is possible.

Though it’s true that many hospitals and physicians serving mostly working-age and Medicare-covered patients are financially stable and offer excellent care, those serving less healthy patients in low-income areas––so-called “safety-net” hospitals—are frequently on the brink of bankruptcy. Survival for many depends on the additional monies brought in by their relatively few well-insured patients and federal subsidies. It would be a disaster for these providers if rates paid by privately insured patients dropped to current Medicare rates.

Hospitals in well-off areas, meanwhile, feast off the higher payments extracted from their well-insured clientele. That’s where the fat in the system is. But lowering their prices to existing Medicare rates would deliver an immediate financial shock to existing operations, generating tremendous pushback from local hospital leaders, physicians, and their elected representatives, regardless of party.

To make a single-price system work economically and politically, then, Medicare payment rates to providers will also need to rise. How much? By 60 percent, I would estimate, based on a real-world test case. When Democratic leaders in Washington offered a publicly funded option on that state’s Obamacare exchange, provider organizations successfully lobbied for payment rates that were 160 percent of Medicare rates––still lower than existing commercial rates, but well above the government program’s rates. They convincingly argued that many hospitals and doctors’ offices could not survive without the cross-subsidization provided by the sky-high prices paid by employer-provided plans.

A single pricing system that made a similar average rate cut for private payers would save employers and their employees, according to my own rough estimate, more than $400 billion a year. That works out to a $1,200 a year reduction in annual premiums for the average working family, or a total of $1,500 a year when administrative savings are added in (presuming employers are mandated to share the savings with their employees).

The problem, of course, is how to finance that extra $400 billion, which will now be coming from the federal government. The obvious fix would be to recapture the $400 billion in employer savings by raising their Medicare taxes by an equal amount (while not raising such taxes on employees).

Financing single pricing in this way will have the additional benefit of boosting manufacturing in the U.S. by making the health care cost burden between firms more progressive. Old-line firms like General Motors, Caterpillar, and John Deere pay the highest premiums because their workforces are older, sicker, and middle-income. Meanwhile, the highly profitable tech titans that now dominate the U.S. economy like Apple, Meta, and Google have workers who are younger, healthier, and better paid. They spend far less per worker for health insurance. Tripling the employer Medicare payroll tax will have the beneficial effect of lowering total health care costs for those firms with older, sicker workforces while raising costs for those businesses with younger, healthier ones.

For this reason, old-line firms with older workers would have good reason to provide crucial political support for the plan. We can also expect, however, well-funded and intense pushback from other corporate sectors that would face sharp payroll tax increases. Their opposition, plus resistance from providers, will make reform a tough road.

But there’s no law saying that the only way to fill the $400 billion gap is by raising Medicare taxes. Other forms of federal revenue would work. Lawmakers could, for instance, tax things that make people less healthy: air pollutants, sugar-laden foods, or other detrimental products. Alternatively, they could pay for the plan by raising tax rates on corporate and top earners—moves that voters overwhelmingly favor. Indeed, much of the plan could be financed merely by closing the insane new loopholes (such as gutting the alternative minimum tax) that the Trump administration is creating for major corporations and wealthy individuals above and beyond the OBBBA.

This would be a huge net advantage to the vast majority of employers, who would be relieved of a significant share of their health care liabilities with no requirement that they pay higher Medicare payroll taxes. And Democrats could mandate that an appropriate portion of that money be rebated to employees in the form of higher pay. In 2024, the total estimated cost to a typical family of four in an employer-provided health plan was around $27,000, according to KFF. If such a family received a 25 percent share of the savings from these reforms, its pretax income would increase by around $4,000.

To win back working- and middle-class voters who already trust them more than Republicans to do the right thing on health care, Democrats need to offer a plan that immediately limits workers’ out-of-pocket costs. For employers, unions, and others who want to “keep what they have,” single pricing tied to annual budgets preserves the employer-based system while providing them with the long-term benefit of slower- growing costs. For the millions of small businesses that don’t currently provide coverage, the plan will make it much cheaper to do so. Such a plan might even win support from the few GOP officials willing to free themselves from the fear-driven grip of Trump’s faux populism.

This article first appeared on The Washington Monthly website.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

Fearing Midterm Ruin, Trump Blinks On Obamacare --Yet Still Aims To Gut Program

Fearing Midterm Ruin, Trump Blinks On Obamacare --Yet Still Aims To Gut Program

Plus ça change, plus c’est la même chose.

President Trump’s health plan, promised by Thanksgiving, was leaked to the press over the weekend. With the frosty reception immediately given this trial balloon by Republicans on Capitol Hill, I doubt it will see the light of day before people gather for their holiday dinners with family and friends.

The leaked plan’s outline went something like this:

  • It offered a two-year extension for the expanded premium subsidies, which Democrats demanded be restored in full during the six-week government shutdown
  • It establishes a minimum monthly payment of $5 for any plan, no matter how poor you are.
  • It would raise premiums for millions of low-income plan purchasers by turning the current cost-sharing formula, which currently lowers premiums, into a reimbursable expense, which will raise premiums.
  • It will establish a new subsidy cliff (when all subsidies stop) at 700 percent of poverty income (about $110,000 for a single adult in 2025).
  • It will allow beneficiaries to shift their tax credits into a health savings account, but only if they buy a bronze or high-deductible plan.

Other press accounts suggested the Trump proposal would also make short-term, limited benefit plans a permanent option on the Obamacare exchanges, and turn their allowable duration (just three months under a Biden administration rule) into years. Trump also wants to ban any government-subsidized plan from providing gender-affirming care or providing care for undocumented immigrants.

If you want more insight into this plan, you can turn to Charles Gaba’s substack or Andrew Sprung’s XPostFactoid. No one knows more about how the exchanges work (or don’t) than those two.

The politics

The only thing new in this plan is its direct relevance to the next two spins of the political cycle. Limiting the subsidy extension to two years gets the Republicans beyond the mid-terms, where they are staring at the possibility of a major shellacking.

Also, if passed, it would guarantee another fight over “failing Obamacare” during the next presidential election. That slogan will ring true to millions of people if the other elements of the plan are enacted, since they will go a long way toward turning a relatively successful program into a failing one.

There’s no need for me to go on at great length about why these rehashed GOP talking points should be non-starters for anyone who cares about health care, or has empathy for the least well-off among us. In short:

  • Any co-premium paid out-of-pocket for the very poor — even $5 — will dissuade hundreds of thousands of not millions from purchasing plans.
  • Turning cost-sharing into a reimbursable expense for the sick will also raise premiums.
  • The new subsidy cliff for the better-off people will incentivized hundreds of thousands if not millions of younger, healthier workers to drop coverage. This raises the average cost of the sicker, poorer patients still in the risk pool, which in turn raises premiums, which in turn discourages even more people from purchasing plans.
  • And, if those younger, healthier workers still want insurance, they will be offered the opportunity to buy those longer-duration, limited benefit plans, which will leave them with huge bills should they actually need to use their insurance. Again, more healthier people out of the risk pool; higher premiums for everyone in the risk pool.

Can you see a pattern? Raise premiums (for 2026), raise premiums (for 2027), and raise premiums (for 2028). Give young, healthy people an out (who cares about those who get sick and can’t afford their high deductibles). Then, let’s have an election where the GOP can point to the “obvious” failures of Obamacare.

As for preventing transgender people and undocumented immigrants from receiving care (whoops, the undocumented are already ineligible), that’s just cruel. It’s especially cruel to the more than half million people brought here as children by undocumented parents, most of whom are now hard-working, taxpaying adults.

Trump has already denied them coverage, reversing an earlier rule. This would make it permanent.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

As Health Insurance Premiums Spike, Inequality Worsens -- But There Is A Solution

As Health Insurance Premiums Spike, Inequality Worsens -- But There Is A Solution

It’s not just people with Obamacare plans who face huge premium spikes next year. Workers with employer-based plans, which cover nearly half of all Americans, are also getting hit with very large increases in their premiums.

The annual survey by Mercer, a major employer benefits consulting firm, found health benefit costs per employee are expected to rise 6.5% in 2026, which would be the highest increase since 2010. Total plan costs-per-employee will increase nine percent, which employers will partially offset by “raising deductibles and other cost-sharing provisions, which can lead to higher out-of-pocket costs for plan members when they seek care.”

One of those “other cost-sharing provisions” — the one that will hit everyone and not just those who get sick — are the co-premiums for their plans, which are taken each week or month out of their paychecks. Historically, employers pick up about 75 percent of the cost of family plans. So when the total costs goes up 6.5 percent, so does the 25 percent share paid by employees.

How much will that cost workers? According to the Kaiser Family Foundation annual survey of employer-based insurance, the average worker paid $6,850 for a family plan in 2025. A 6.5 percent increase in 2026 will sap paychecks by an average of $445. That’s nearly a one percent reduction in the median worker’s take-home pay.


Source: Kaiser Family Foundation

This has gone on for the decades, and will continue as long as health care costs rise faster than wages. A study published in JAMA Network Open last year calculated lost earnings from the growth in health insurance premiums between 1988 to 2019 cost the average family over $125,000 in inflation-adjusted dollars, or nearly 5% of total earnings over the entire 32-year period.

Low-wage workers bear the brunt

But averages don’t tell the whole story. The income-sapping surge in co-premiums for health insurance hits low-income workers much harder than high-income workers because of the way employers structure their health insurance plans.

Most employers that offer health insurance to their employees provide three plan options. The most expensive is the preferred provider organization (PPO) plan. The middle-priced option is usually a health maintenance organization (HMO) plan, which places limits on provider choice. And then there is the high-deductible plan, which is the least expensive but can leave plan participants with huge and unaffordable bills when they get sick.

Not surprisingly, the lowest cost high-deductible option is most attractive to employers’ lowest-paid workers, who are desperate to hold down their upfront health care costs because they need the cash to pay other bills. Middle-income workers may opt for the HMOs, while upper income employees are the most likely to opt for the PPO plans. They can afford them, and they appreciate the ability to see any doctor they choose.

Most employers unwittingly exacerbate this class stratification in private health insurance. More than three-quarters of employers charge every employee, no matter what their income, the same co-premium within each plan option, according to a 2019 Bureau of Labor Statistics survey. Everyone who choose an HMO plan, for instance, faces the same co-premium. That means lower wage workers are paying a higher share of their income for health insurance compared to others who choose the same plan.

Time to graduate

There is a way to bring greater equity to employer-based health insurance. It is something more employers should consider given the growth in income inequality over the past half century.

They could adopt income-based co-premiums, which are sometimes called tiered co-premiums. In a tiered system, those with the lowest incomes pay lower co-premiums for any of the three choices, while those with higher incomes pay more for the same plans. Tiered co-premiums operate like a graduated income tax.

For example, Honolulu-based Alexander & Baldwin, a real estate firm, dropped its one-size-fits-all co-premium structure in 2023. It established three tiers for its more than 100 employees. A single worker in the lowest salary range paid $42 a month for an HMO plan; the middle salary range paid $67 a month for the same plan; and the highest paid workers paid $92 a month.

Universal tiering of co-premiums — something that could be mandated by federal regulation — will not address the burden placed on all Americans by rising health care costs, which this year are being driven by exorbitant hospital and drug prices, rapid uptake of weight-loss drugs, and soaring costs for imported medical products due to Trump’s tariffs. But it will bring equity when it comes to bearing the burden of those rising costs.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

How Trump's Patent Office Appointees And Big Pharma Delay Low-Cost Drugs

How Trump's Patent Office Appointees And Big Pharma Delay Low-Cost Drugs

What’s the easiest and smartest thing a president could do right now to bring down drug prices? That’s easy. Allow quicker market entry for generic versions of biologics.

What’s the biggest thing the Trump administration has done in recent months to impact biologic prices? It made it far more difficult for biologic generics, better known as biosimilars, to enter the market.

How did that happen when the president is constantly using his Truth Social platform to brag about how much he’s doing to lower the price of drugs? He appointed leaders at the Patent and Trademark Office (PTO) who are imposing policies that will make it far more difficult for biosimilar manufacturers to challenge improperly granted patents.

They are already allowing Big Pharma companies to maintain their illegitimate patent portfolios, known as patent thickets, which they use to deny market entry to cheap, generic competitors. These delays can last for years — even decades — beyond the expiration of an initial patent.

Why is this such a big deal and such a big gift to Big Pharma? While biologics make up only two to five percent of prescriptions (estimates vary), they generated around half of the pharmaceutical industry’s $634 billion in revenue in 2024. When still on patent, the price of individual biologic treatments can reach as high as several hundred thousand dollars per year. But when biosimilars enter the market, patients and their insurers save nearly 80 percent on average, according to a recent study in Health Affairs.

Before I get into the shenanigans at the PTO and how it will delay biosimilars, allow me to share some background for those not familiar with the complexities of the pharmaceutical industry and its biotechnology offspring, which was birthed by government-funded inventions that began in the mid-1970s.

Biologics are large organic molecules produced through genetic engineering that are usually delivered through injection or intravenous drips. Many of the greatest advances in drug therapy over the past half century have been through biologics.

The genomic revolution allowed scientists to replace proteins that patients’ bodies cannot produce because they have organ failure or genetic mutations. Genetic engineers also created monoclonal antibodies that target specific cancer mutations and the blood vessels that feed tumors. Vaccines are biologics. Scientists are now working on gene therapies that may permanently repair genetic birth defects.

Producers of biologics – like all drug makers – get patents on their inventions, a right guaranteed in the Constitution (thank you, James Madison) to promote innovation in “science and useful arts.” The idea was to create a limited period that incentivized creation of new inventions, but eventually ended so patent owners couldn’t use their patent monopoly to permanently levy exorbitant prices.

Patent terms have been changed repeatedly over the nation’s history. In 1994, Congress established a 20-year term for patents that began with the date of filing, an increase from the previous 17 years. In 2010 it added a 12-year guarantee of exclusivity to biologic manufacturers, whose products often remain in development for years after the initial patents are filed.

While that add-on was controversial, potential biosimilar manufacturers embraced the bill because it finally provided them with a pathway for entering the market. They also stood to benefit from the 2011 America Invents Act, which created a streamlined process at the PTO for challenging questionable patents. Instead of long and costly litigation in federal court, patent challenges would be heard by expert judges inside the PTO at a fraction of the cost. Appeals would be heard by an internal appeals board.

Information technology’s role

The impetus for the streamlined challenge process came from leading information technology firms (Google, Amazon, Facebook, etc.) who were being besieged by so-called patent trolls, who would buy or write patents they never intended to use that were similar to cutting edge info-tech technologies. The trolls, often backed by private equity investors, used those patents to file patent infringement lawsuits against well-heeled high-tech firms who had actually developed, patented, and used similar technologies. The goal: To extract huge settlements through patent purchases or licensing fees.

One major user of the new challenge process, called inter partes reviews (IPRs), turned out to be biosimilar manufacturers, who wanted a faster and cheaper way to challenge the patent thickets being erected by Big Pharma and biotech firms. Virtually every company that produces FDA-approved biologics and small molecule drugs (pills and capsules) files follow-on patents at the PTO. Any individual product may win a dozen or more, usually involving small changes in dosages, formulations or routes of administration.

“By creating large patent portfolios, companies can make it more difficult for competitors to enter the market by increasing transaction costs and/or delaying US Food and Drug Administration (FDA) approval,” law professors Sean Tu of the University of Alabama and Ana Santos Rutschman of Villanova University wrote this month in JAMA Health Forum. “Patent thickets can also be leveraged to force competitors to settle litigation, thus delaying market entry, or to enter under unfavorable conditions (such as restricted volume entry).”

One study they cited showed 78 percent of all “new” drug patents are part of a post-approval patent thicket for an already approved drug. This tactic has slowed adoption of biosimilars to a crawl. Fifteen years after passage of the law creating a pathway for biosimilar market entry, there are still fewer than 50 on the market, despite there being over 600 FDA-approved biologics, according to the Association for Accessible Medicines, the trade group for biosimilar manufacturers.

The process sped up during the Biden administration as biosimilar manufacturers increasingly turned to the IPR process to challenge questionable patents. They were aided by the fact that the administrative process at the PTO takes only 12 months and costs about $725,000, according to another recent paper co-authored by Tu. Patent litigation in federal court, by contrast, costs on average over $6 million and takes years to resolve.

Biosimilar manufacturers started racking up an impressive IPR win rate at the PTO. Another recent study showed biosimilar manufacturers won 14 of 20 challenges that were holding up market entry for their products. They eventually won FDA approval and saved patients and their insurers tens of billions of dollars. Five are shown in the following chart.

(Note: The bottom scale (-4 to 4) represents the years before and after a biosimilar manufacturer won a patent invalidation case at the PTO. The solid lines represent five of the more expensive biologics that lost exclusivity over the past decade. In each case, the sharp drop in revenue due to lost sales to biosimilars didn’t show up until a year after the PTO ruled because the Big Pharma firm defending the patents had a year to appeal. The bottom dotted line shows how one representative biologic that didn’t face biosimilar competition more than doubled its revenue over a similar time period.)

Big changes at PTO

But the PTO reversed field this year. PTO acting director Coke Morgan Stewart, who had worked at PTO during the first Trump administration before joining O’Melveny & Myers, a major corporate law firm, began using a process she dubbed “discretionary denial” to block patent challenges. In 2024, the patent appeals board had approved nearly 75 percent of all patent challenges. By September of this year, the first under Trump, that rate had declined to 35 percent, according to another study by Tu, this time with Arti Rai of Duke University and Aaron Kesselheim of Harvard Medical School.

The scholars reviewed Stewart’s decisions and found she had created a novel rationale for dismissing patent challenges. She argued that after six years (about the average age for drug patents being challenged), the patent holder should expect they will no longer be administratively challenged. “Before 2025, the ‘settled expectations’ rationale never even existed,” Tu and his colleagues wrote. “It now accounts for a large percentage of denials and is even used when administrative review petitions raise reasonable technical grounds for invalidation.”

In September, the Senate approved John Squires to run the PTO, though he is not a registered patent attorney. He did chair the Emerging Companies and Intellectual Property practice at Dilworth Paxson LLP in Washington where he represented numerous AI, blockchain, crypto, and financial technology companies. He also made campaign contributions to both of Donald Trump’s victorious election campaigns and more recently to the Never Surrender PAC, which is one of the president’s vehicles for supporting GOP candidates in the 2026 mid-term elections.

One of Squires’ first acts after winning Senate approval was to centralize the IPR decision-making process in the director’s office, thus removing it from the experts who understood the technical issues. He also limited the length of briefs that petitioners could file. Then, in mid-October, Squires announced that “he would personally decide every IPR proceeding,” which cannot be reviewed judicially. He also declared he could issue “summary notices,” that may include little or no explanation for denials.

“By aggressively invoking discretionary denials, the USPTO is subverting an important administrative pathway that Congress specifically created to check weak patents,” Tu, Rai and Kesselheim wrote. Seven lawsuits have already been filed challenging the new policy. They call on Congress to “step in” and “explicitly prohibit denials based on non-merit-based criteria such as ‘settled expectations’.”

This Congress? Fat chance. Look for a dramatic slowdown in the pace of biosimilar adoption over the next few years and for a continuing sharp rise in consumer and payer spending on biologics, the most expensive drugs on the market.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

'The Ideas Are There': Shutdown End Signals Renewed GOP Assault On Health Care

'The Ideas Are There': Shutdown End Signals Renewed GOP Assault On Health Care

First they came for the federal employees. Then they slashed food stamps. And now that the Democrats have surrendered in their fight to preserve expanded Affordable Care Act subsidies and Medicaid funding, expect to see a full-blown attempt by the GOP to gut the individual market in December.

Fresh off their overwhelming victories in last week’s off-year elections, a handful of Democratic centrists decided the possibility of delayed Thanksgiving travel plans was the bridge too far when it comes to protecting millions of people from losing their health insurance.

I put the odds of the Democrats winning concessions in the promised December negotiations — if they actually take place — at about five percent. Why would the Trump-owned GOP agree to even a one-year extension of expanded subsidies when they are planning to offer their own plans for “lowering premiums” during next year’s mid-term election campaigns?

This morning’s Modern Healthcare reports GOP leaders are planning to reintroduce many of the same policies they floated but failed to pass in their many efforts to repeal Obamacare during Trump’s first term in office. They include rejiggering the original ACA subsidies so that people buying plans on the exchanges pay lower premiums but have higher co-pays and deductibles.

Also under consideration is expanding the amount of money people can put into health savings accounts to defray their out-of-pocket expenses. This is meaningless for most lower-wage workers — the ones hurt most when thrown into high-deductible plans. They can’t afford to take money out of their paychecks to put into a health care rainy day fund. Such policies are a gift to the well-insured upper middle class, not people in the bottom half of the wage distribution.

GOP efforts to pose as defenders of health care will also include a push to eliminate restrictions on short-term plans, which the Biden administration had limited to three-months duration. Such plans, which have none of the guaranteed coverage or cost controls included in ACA plans, were originally conceived as a bridge for people between jobs.

The Trump administration announced in August it wouldn’t enforce the Biden rule. At the time, it said it plans to promulgate new rules giving such plans a one-year duration and allow people to stay on them for three consecutive years. Passing a law would get that job done more quickly.

They also want to bring back association plans, where industry, religious, or other groups can set up cooperative insurance schemes that meet none of the consumer protections in the ACA. Those include guaranteed issue (where you can’t be denied coverage if you have an existing medical condition); caps on out-of-pocket expenses; and requirements that plans offer benefits deemed essential like mental health and substance abuse treatment; pregnancy, maternity and newborn care; and preventive and wellness services.

A suite of changes like that will give young, healthy workers without employer-based coverage numerous low-cost options that enable them to bypass the exchanges when seeking coverage. Brokers will gladly push such plans since they make huge and repeated commissions through their sale. This will drain the insurance pool of healthy workers, leave behind a sicker insurance pool, and thus raise premiums for everyone who needs more comprehensive insurance.

“We have discussions ongoing right now, and I think for any side to say the Republicans don’t have ideas for healthcare reform is to forget what we went through and almost got done,” House Education and Workforce Committee Chair Tim Walberg (R-MI) told Modern Healthcare in an interview. “The ideas are there.” (Editor's note: Another Walberg idea was launching nuclear strikes in Gaza to "get it over quick.")

And they’re moving to enact them. The Senate Homeland Security and Government Affairs Committee held a hearing last week to discuss a new insurance pool that would provide catastrophic health coverage for skimpy individual plans sold outside the exchanges. Numerous states tried this prior to passage of the ACA. In every case the plans were deemed inadequate and often foundered because of their high premiums, exclusions for pre-existing conditions, and annual and lifetime limits. Some states were forced to cap enrollment to limit costs.

Why the capitulation?

Some pundits are reporting that the Democratic capitulation “was all about the filibuster.” Others suggest the cutoff of food stamps was a larger issue. “Trump was purposefully making the shutdown hurt as many people as possible,” wrote Bill Scher of Washington Monthly. Yet “little in this deal is going to prevent him from inflicting further harm.”

The morning headlines in the Kaiser Health News daily feed said it all. “The Trump administration is telling states not to pay full November food stamp benefits, revising its previous guidance after winning a temporary victory at the Supreme Court on Friday,” Politico reported.

Iowa Public Radio reports the federal government ordered states to start enforcing a part of the One Big (Ugly) Bill that cuts off food assistance for refugees and many other types of immigrants with legal status. The Conversation reports the National 211 Hotline has seen calls for food assistance quadruple in recent days, to levels typically seen during natural disasters.

“Shockingly, President Trump and his allies were willing to cut off food assistance to children and fire federal public servants rather than to simply extend an existing tax credit to prevent a premium price spike of hundreds or thousands of dollars for millions of Americans,” Anthony Wright, executive director of Families USA, said in a statement this morning.

“While we are relieved to finally see an end to the longest government shutdown in history — getting federal workers back on the job and ensuring that essential safety net programs like the Supplemental Nutrition Assistance Program (SNAP) can continue — we must continue the fight to contain health costs,” he said. “Americans need a permanent extension of help for health care premiums, and a broader effort to address health care affordability overall.”

There is definitely a health care affordability crisis. It is being made worse by the Trump regime. I spent some time this morning looking at how out-of-pocket health care expenses are affecting different classes of Americans. Here’s what I found:

...

It’s time for the politicians to start coming up with real solutions to the affordability crisis that is hitting not just people on ACA plans or on Medicaid, but on the broader population. The Trump regime is only making things worse.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

As Insurance Costs Surge, GOP No Longer Pretends To Support Universal Coverage

As Insurance Costs Surge, GOP No Longer Pretends To Support Universal Coverage

The Trump administration’s wrecking ball has succeeded in shattering one of the core beliefs of centrist health care reformers, which states: Incremental reforms will eventually lead the U.S. to the promised land of health insurance for all—something most advanced industrial nations achieved more than 75 years ago.

Even many Republicans once signed onto the gradualist approach to achieving the goal of universal coverage. In the early 1970s, President Richard Nixon proposed covering everyone through insurance industry-managed plans. In the 1990s, a Republican-controlled Congress authorized universal coverage for children. Even President Trump in 2017 vowed to replace Obama’s Affordable Care Act with a new plan that would provide “insurance for everyone.” Ultimately, he failed to either release a plan or repeal Obamacare.

But now, for the first time in its history, the U.S. is making a sharp U-turn on the long road to health care for all. The GOP not even pretending that universal coverage is a desirable national goal. It is deliberately raising the ranks of the uninsured.

The One Big Ugly (not Beautiful) Bill signed by the president last July will drive an estimated 17 million people from the insurance rolls by 2034, according to KFF. More than two-thirds of those losses will come from cuts to Medicaid. Half those cuts, which establish bureaucratic roadblocks for obtaining coverage, won’t be reversed even if the Democrats succeed in forcing concessions from the majority party during the shutdown negotiations, which are still underway as of this writing.

Thanks to legislation Democrats passed during Joe Biden’s administration, the national uninsured rate fell last year to 8 percent, which is within hailing distance of universal coverage (generally considered to be five percent or less). Some states are already below that threshold, which might have occurred nationally had not ten Republican-run states, including populous Texas (still 16.4 percent uninsured) and Florida (10.9 percent), refused to expand Medicaid to cover the working poor. That overall rate is certain to rise next year and for the rest of this decade. If no changes are made, it will soar into the mid-teens, nearly to the levels seen before the Affordable Care Act passed in 2010.

Universal coverage doesn’t guarantee Americans will enjoy better health. Nor does it ensure health care will be affordable. However, it is inconceivable that either of those goals can be achieved without universal coverage, which is a necessary, though not sufficient, condition for addressing the long-term health care cost crisis affecting most American households.

Step by step

The incrementalist strategy emerged in the wake of President Harry Truman’s failed attempt after World War II to implement a government-run, universal health insurance plan, similar to those adopted by many European countries. Opposition from the American Medical Association, labor unions with their newly negotiated employer-based plans, and a burgeoning health insurance industry doomed the bill.

But calls for universal coverage never ceased. A decade-and-a-half later, with the White House and Congress in Democratic hands after Lyndon B. Johnson’s 1964 landslide, the government created Medicare and Medicaid for the old, disabled, and poor. In 1997, after the Bill Clinton administration’s significant push for universal coverage failed, a Republican-led Congress included a separate plan for uninsured children in the Balanced Budget Act.

Then, in 2010, with Barack Obama in the White House and the country reeling from the Great Recession, a Democratic Congress passed the Affordable Care Act. It created a subsidized individual market for those without employer coverage; expanded Medicaid to include individuals and families earning up to 137 percent of the poverty level; and began experimenting with a host of delivery system reforms to hold down costs.

However, cost-saving measures cannot be effective unless everyone is in the insurance pool. Uninsured individuals often postpone necessary but non-emergency care. When they become so sick that they must seek care, they show up in emergency rooms, where care is the most expensive, and where their outcomes are usually worse because they waited too long. For their troubles, they are often saddled with unpaid debts.

More uninsured hurts everyone

The dysfunction wrought by a growing pool of uninsured people affects everyone’s pocketbook. Providers and insurers use the uninsured’s unpaid bills as an excuse to pass along those expenses in the form of higher prices to the privately insured, who already pay 2 ½ times what Medicare recipients pay on average. This results in not just more expensive plans for employers (the median family plan cost a staggering $27,000 in 2025), but higher co-premiums, co-pays, and deductibles for their employees, whose share of the total cost of “employer-financed” care has hovered between 25 and 30 percent for decades. (I put scare quotes around “employer-financed” because employer contributions are a tax-deductible business expense that otherwise would go to workers as wages if it weren’t spent on benefits.)

Universal coverage doesn’t guarantee that health care will become more affordable for everyone. But it reduces the level of more expensive, uncompensated care in the system, which is necessary to lower prices for everyone, including private insurers and their employer customers. Universal coverage is a crucial prerequisite for achieving more affordable health care.

Yet now, under Trump and a supine Republican Congress, America is deliberately reducing the ranks of the insured. The process has already begun. Premiums for individual plans being sold on the exchanges for next year are soaring due to the expiration of enhanced subsidies, which will discourage many people from buying plans.

Though the bill’s new Medicaid work requirements were postponed until after the 2026 mid-term elections to hide their full effects from voters, states were given the green light to begin enforcing twice-annual recertification requirements. Many red states are already moving to do that, as well as cut their Medicaid spending in response to the cutbacks in federal support for the joint federal-state program. Millions of low-wage workers will start losing their Medicaid coverage next year, not because they aren’t working, but because they become frustrated by the paperwork requirements set up by hostile bureaucrats beholden to their Republican overlords.

Democrats on Capitol Hill are singularly focused on maintaining the enhanced subsidies and restoring the cuts in Medicaid financing. That means the work requirements and other bureaucratic roadblocks will remain because they can’t be addressed in a reconciliation bill. No matter how the shutdown is resolved, a sharp decline in both coverage and access is inevitable.

That will financially harm almost everyone covered by employer-sponsored plans. This year, those rates soared at twice the inflation rate on average, according to the annual KFF employer survey of just under 1,300 firms. Mercer, a leading benefits consulting firm, says rates will rise by a similar level next year. Plan structures will undoubtedly include higher co-payments, higher deductibles, and higher co-premiums for workers and their families.

No matter how the government shutdown is resolved, the health care affordability crisis, exacerbated by the historic GOP U-turn on universal coverage, will remain a salient issue during next year’s House and Senate campaigns. The only question is whether Democrats will be able to take advantage by offering a program that addresses voters’ number one concern when it comes to health care.

This story first appeared on the Washington Monthly website.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News


Inside Kennedy's FDA, Chaos Reigns And Fear Of Corruption Rises

Inside Kennedy's FDA, Chaos Reigns And Fear Of Corruption Rises

The chaos inside the Food and Drug Administration reached new heights last weekend with the forced resignation of the chief of the agency’s main drug approval division, a former biotech executive just five months into the job.

Center for Drug Evaluation and Research (CDER) director George F. Tidmarsh resigned Sunday after FDA commissioner Marty Makary put him on administrative leave and locked him out of his email account. Makary moved against Tidmarsh on Saturday after he was sued the previous day by a company owned by his former business partner.

The complaint? Tidmarsh used his government position “to inflict financial harm” on Kevin Tang’s Aurinia Pharmaceuticals, where the two apparently had had a falling out.

Then, after his resignation on Sunday, Tidmarsh gave an expansive interview to Stat, an industry-oriented online news organization, where he all but accused Vinay Prasad, the director of the Center for Biologics Evaluation and Research (CBER), of being behind his ouster. Dozens of FDA scientists have fled CBER in recent months due to the unstable, personalized nature of Prasad’s leadership.

Stat ran an article on Friday documenting slumping morale and a climate “rife with mistrust and paranoia” at CBER, where seven top leaders have been fired in recent months. Hundreds of the sub-agency’s 1,100 employees have quit or retired since Prasad joined the administration. Those that remain “are terrified of pushing back on Prasad, lest they face retaliation.”

(Prasad was briefly fired in July after being attacked by rightwing influencer Laura Loomer for questioning some drug approvals and criticizing President Trump, which happened years before he joining the administration; for more on the rightward march of Prasad’s career, see this GoozNews post. He was rehired two weeks later.)

When first hired, Prasad immediately put his division’s top gene therapy regulator, Nicole Verdun, on administrative leave based on accusations she was a bad manager. Stat reported over the weekend she will return to her job after an investigation found her behavior toward subordinates did not warrant permanent removal.

But the real reason Prasad went after Verdun was for her highly controversial approval of the gene therapy for Duchenne’s muscular dystrophy, which showed minimal improvement in patients’ lives. Prasad has generally stayed true to his philosophy that drugs whose clinical trials show questionable efficacy should not gain FDA approval. His initial appointment to run CBER caused biotech stocks to temporarily sink since questionable efficacy is an accurate description of many recent drug approvals.

Power play

Prasad has been busy accruing power since he was rehired in August. He regained his appointment as chief medical and scientific officer for the entire agency in September. Last month, he removed the scientist in charge of vaccine approvals, Anuja Rastogi, a move clearly in line with the anti-vaccine priorities of his ultimate boss, HHS Secretary Robert F. Kennedy, Jr.

According to Stat, Prasad has also removed Sandra Retzky, head of orphan products, and Daniel Singer, the chief of public health preparedness and response. The leaders of the pediatric therapeutics and clinical policy departments have resigned. Its interviews with agency employees, none of whom were willing to go on the record, suggest employees who remain at the agency are buckling under the workload.

Meanwhile, the agency is moving quickly to create an alternative “accelerated” pathway to gain drug approvals that bypasses the usual scientific process at FDA. In June, it created it is calling a National Priority Voucher program where agency officials will “select” drugs eligible for rapid reviews of their new drug applications. The drugs chosen will be “for companies aligned with critical national health priorities,” which were not specified. The reviews will take just 1-2 months instead of the usual 10-12 months. They will be conducted by a “tumor board stye review process,” run by a committee chaired by Prasad.

Numerous critics have warned this new process will substitute review by expert opinion rather than scientific evidence. Even the libertarian Cato Institute warns the application and review process under these priority vouchers will “heavily incentivize rent-seeking, lobbying, corruption, and excessive bureaucratic discretion in drug value assessments.”

Prior to his ouster, Tidmarsh questioned Prasad and Makary about the new “tumor board-style” committee's legality. “It was a total mess,” Tidmarsh told Stat on Sunday. “It was shrouded in secrecy and paranoia. So I sent an email saying I believe that this (first) meeting will be informal, non-decisionary.” In mid-October, the FDA announced the first nine drug companies whose new drug applications will receive the new accelerated process. Several would have been reviewed by CBER.

Tidmarsh also expressed deep fear about the future of the FDA and the uncertainty of the U.S. regulatory environment. “This is an existential threat to the FDA,” Tidmarsh told Stat. “Something’s got to be done.”

Tidmarsh is no heroic figure. Let me quote extensively from Stat’s report on the Aurinia Pharmaceutical lawsuit against him:

On Aug. 6, the FDA announced it was barring the sale of (Aurinia’s) naturally derived medicines, called desiccated thyroid extract, or DTE, after receiving hundreds of adverse event reports. The products have been prescribed for more than a century to treat people with low thyroid hormone levels and predate the FDA’s formal approval process. More than 1 million Americans use DTE products to treat low hormone levels.
Aurinia accused Tidmarsh of making “false and defamatory statements” about the company and voclosporin (the generic name for DTE) due to a “longstanding personal vendetta against Kevin Tang (Aurinia’s majority owner).” Tidmarsh also directed the FDA to remove DTE products from the market because it would hurt American Laboratories, which is majority owned by Tang, the Aurinia lawsuit alleges.
The lawsuit includes an email said to have been sent by Tidmarsh to Tang with a link to Tidmarsh’s LinkedIn post saying the products should be removed from the market. The subject line was “Good Luck.”

Tidmarsh began his career and earned his initial fortune before 2008 while CEO of Horizon Pharma. During his tenure, Horizon developed an arthritis pain medicine called Duexis, which combined two over-the-counter drugs – ibuprofen and the active ingredient in Pepcid, an antiacid. The now on-patent drug sold for $1,500 a month and was eventually sold as part of a suite of Horizon products to Amgen for $28 billion in 2022 – long after Tidmarsh left the company.

Still, Tidmarsh proudly claims development of Duexis as one of his major achievements on his Stanford University profile.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

Overpriced And Overhyped: Is Medicare Advantage Sliding Downhill?

Overpriced And Overhyped: Is Medicare Advantage Sliding Downhill?

Ready for a raucous yet serious look at Medicare Advantage? Check out HBO’s Last Week Tonight with John Oliver from this past weekend:

- YouTube youtube.com

No need to recap its highlights here, since I’ve written frequently about all of the issues he raises in his half-hour show.

But I did want to highlight what is going on in the Medicare Advantage marketplace now that open enrollment is underway. I reported earlier this month about how most major insurers are cutting back their MA plan offerings, abandoning costly regions and even some states.

Now we’re finally getting some sense of the scale of those cutbacks. After reporting UnitedHealth’s third quarter earnings on Tuesday, CEO Stephen Hemsley told stock analysts the company expects to lose about one million Medicare Advantage members for the 2026 plan year or about 12 percent of the company’s total 2025 MA enrollment.

That’s a stunningly high number. If other companies selling MA plans experience even half that level of decline, the privatized share of the total Medicare market will fall well below half and could wind up as low as 45 percent in 2026.

UnitedHealth blamed rising costs due to greater utilization and higher provider prices for the declining profitability of its MA segment. Its medical loss ratio (the share of revenue spent on actual health care) rose to 89.9 percent in the third quarter, up from 85.2% a year ago. The government requires insurers spend at least 85 percent of their premiums on providing care. The rest gets spent on overhead, marketing and profits, which until this year were quite hefty, largely due to overpriced (to the government, that is) MA plans.

There may be an additional reason for the company’s declining profitability, which fell 61 percent from a year ago despite revenue growing 12 percent in the third quarter. Doctors and nurses are beginning to question the company’s upcoding strategy, where it incentivizes clinicians to diagnose diseases for inclusion in patient charts despite the fact those diseases are not being treated or in need of treatment.

For example, as John Oliver reported in his piece, UnitedHealth documented over a three-year period 246,000 cases of secondary hyperaldosteronism (oversecretion of a blood pressure-regulating hormone in patients with heart, liver and kidney disease), even though they never tested for aldosterone. This single upcoding scheme resulted in $450 million in additional government payouts to UnitedHealth. As a former house calls nurse told Oliver, “In a million years, I wouldn’t have come up with a diagnosis like secondary hyperaldosteronism.”

Why might clinicians be backing away from participating in the schemes? STAT reports this morning that UnitedHealth wants to turn more of its 90,000 affiliated physicians into full-time employees. Currently, nearly 90 percent of those doctors remain in independent practices despite have signed contracts with United that involve some form of “value-based” payment arrangements. Those usually involve some form of shared savings, where the physician practices earn bonuses if they hold down total spending on their patients.

But some of these physician practices (and the nurses they send into homes to document untreated conditions) are balking at a scheme whose only purpose is to inflate Medicare’s per-patient-per-month flat fee for each patient, which is risk adjusted to reflect existing medical conditions. As STAT noted in its report:

“A number of current and former UnitedHealth doctors who complained about the way the company micromanaged their practices and forced them to focus on coding patients above all else. … Documents provided to STAT showed UnitedHealth offered some of them $10,000 bonuses and prepared dashboards showing the top performers.”

It’s possible “they simply want to get rid of physicians who balk at adding untreated diagnoses to patient profiles,” STAT concluded.

Extra fees for hospital systems

Clinicians have other reasons for wanting to back away from treating MA patients. Modern Healthcare reported this morning that Elevance Health (previously known as the for-profit Anthem Blue Cross Blue Shield) will begin tacking on a 10 percent administrative penalty if health systems make referrals to out-of-network specialists and other providers. While the policy will only affect its commercial insurance market at first, it will likely be expanded to include Elevance’s more than two million MA enrollees if they get away with it, which some experts doubt.

“You cannot get away with shoveling billions out the door to your shareholders in the form of share buybacks and then turn around and gouge hospitals facing huge Medicaid payment cuts,” Jeff Goldsmith, president of consultancy Health Futures, told Modern Healthcare. “Expect a gigantic middle finger from the provider community and a lot more leaving Elevance networks.”

Many MA plans are also cutting back on the extra benefits they offer seniors who are in the program.

So here’s the landscape as we head deeper into open enrollment season. Insurers are cutting benefits, squeezing physicians, and narrowing networks. This insurer response to declining profits — and this is even before the Centers for Medicare and Medicaid Services makes serious cuts in the excessive payments to MA plans — ensures MA’s share of Medicare’s total enrollment will fall next year.

The only thing that could stop it now would be for Congress to come up with a bailout. I wouldn’t put it past them to try to include it the reconciliation bill that finally reopens the government, especially if they compromise on the main issues Democrats have put on the table: Restoring the enhanced premiums subsidies for ACA plans and eliminating the Medicaid cuts.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

Republicans Push Skimpy, Unaffordable Health Coverage As Costs Keep Rising

Republicans Push Skimpy, Unaffordable Health Coverage As Costs Keep Rising

The median cost of employer-based health insurance this year leaped ahead at nearly twice the rate of the consumer price index, according to the annual Kaiser Family Foundation employer survey released yesterday. Sadly, workers are bearing a larger share of the increased burden through rapidly rising co-premiums.

The press coverage this morning of the closely followed survey emphasized the combined top-line increase of 5.5 percent for a family plan, which now stands at a staggering $26,993 a year or about the price of a new compact car. The cost of an employer-based individual plan rose at the slightly lower rate of 4.6 percent to $9,325 a year.

But a deeper dive into the numbers provides a better understanding of why people are so upset about rising health care costs. Employee co-premiums for a family plan (the amount deducted from paychecks) rose 7.6 percent on average to $6,850. The employer share went up only 4.8 percent. The net effect was a downward shift in the share paid by employers and a corresponding upward shift in the share paid by their employees, which was a half percentage point more or 25.4 percent of the total.

This increased burden on workers comes after an eight-year period when the employer share of premiums rose fairly steadily (with a few years off early in the pandemic). Companies offset some of those increases by funneling more of their workers into plans that raised their out-of-pocket expenses for deductibles and co-pays.

Depending on the plan type (HMO, PPO, high-deductible), the average deductible from employer-based family plans now ranges from $3,118 to $5,095 a year. Fully a third of workers and their families enrolled in high-deductible plans for 2025, up from 28 percent the previous year and the most ever.

Put the two together, and the median family (half pay more, half pay less) now pays anywhere from $9,968 to $11,945 a year for health care or close to $1,000 a month. Given the median household income in 2024 stood at $83,730, that translates into anywhere from 12 percent to 14 percent of a typical family’s income.

Things are about to get a lot worse. Next year’s premiums and co-premiums for employer-based plans, which cover an estimated 154 million people, are set to rise six percent to seven percent, according to a new survey by Mercer, a health care benefits consulting firm. If the split between employers and their employees remains the same, that will exceed wage increases by two to three percentage points. Wage increases have been trending down for the past three years, falling to just 4.1 percent this past August, the last month reported by the Bureau of Labor Statistics before the government shutdown.

Source: Atlanta Federal Reserve

No wonder health care costs now ranks as the second most important issue for inflation-weary Americans, just behind the deteriorating state of the overall economy. More than four in five of 1,300 adults surveyed in mid-October by the Associated Press and the NORC Center for Public Affairs said health care issues were extremely or very important to them personally. That was nine percentage points more than crime and 23 percentage points ahead of immigration — the next two biggest concerns.

The impact of ACA/Medicaid cuts on employer plans

The outlook for employer-based plans will also get a lot worse if Democrats fail to restore the Medicaid cuts and the enhanced subsidies for Affordable Care Act plans (which provides affordable insurance for tens of millions of low-wage workers, gig workers and sole proprietors). An estimated 7.3 million people who purchased subsidized exchange plans will drop ACA coverage, with more than half becoming uninsured, according to a Commonwealth Fund brief.

Many will look for cheaper, non-ACA compliant plans that don’t quality for listing on the exchanges because they provide skimpier benefits, are not required to provide free preventive care, can discriminate based on prior medical conditions, and often carry extremely high deductibles and co-pays. This summer, the Trump administration announced it wouldn’t enforce the rule approved by the Biden administration in mid-2024 that limited such plans to three months duration.

“Those who sell non-ACA plans … will absolutely see the coming open enrollment as an opportunity to push their plans as more affordable alternatives, without sharing full information with consumers about the limits of those plans,” said JoAnn Volk, a professor at Georgetown University’s Center on Health Insurance Reforms.

What happens when people who previously had Obamacare buy skimpy plans or become uninsured? They postpone care until their conditions require emergency room treatment — the most expensive place to obtain health care. When struck by serious illnesses like cancer, heart attacks and strokes, they often fail to pay their uncovered bills, or resort to Go Fund Me campaigns to pay off their high deductibles. Some will negotiate long-payoff periods and live the rest of their lives burdened by medical debt. Some will declare bankruptcy.

Hospitals and physicians, in turn, will raise their prices to cover the cost of uncompensated care, which will cause private insurance rates to rise even more. Rising prices, rising insurance premiums, and rising uninsured rates is an accurate description of what existed in the U.S. before passage of the ACA.

These health care economic fundamentals are of little interest to the modern-day Republican Party, which invariably includes some variation of bare-bones insurance as one of their answers to the affordability crisis. Early in the shutdown, they floated ideas like instituting new income caps on Obamacare subsidies, establishing minimum co-pays, and cutting off subsidies for new enrollees, none of which they would agree to negotiate until the government is reopened.

Then, last week, Politico reported they are also willing to beef up tax credits for investing in health savings accounts, which could be used to buy skimpy plans. Lower-income workers generally avoid HSAs since they can’t afford the voluntary deductions needed to fund them.

I can’t predict when or how the shutdown crisis will end. But I am pretty confident that I know what will happen to health care costs in the next few years given Republican control of Washington. They’re going up, up, and up.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

Now Republicans Are Using Hunger As A Weapon In Shutdown Fight

Now Republicans Are Using Hunger As A Weapon In Shutdown Fight

Starving a poor, defenseless population worked in Gaza. Why not try it in the U.S.?

That seems to be the Trump regime’s emerging tactic for ratcheting up pressure on the Democratic Party to abandon its attempt to restore the Medicare cuts and Obamacare subsidies as the price for reopening the government.

In mid-October, the Department of Agriculture told every state agency administering the Supplemental Nutrition Assistance Program that they should stop sending in monthly files with the names of beneficiaries. Those files are used to send electronic food-stamp cards worth an average of $187 a month to more than 41 million people across the U.S. That’s one in out of every eight Americans.

During previous government shutdowns, Congress took steps to assure food assistance continued to flow. Earlier this year, the Republican-controlled Congress and the Trump administration agreed to an additional $300 million for the Special Supplemental Nutritional Program for Women, Infants and Children. WIC provides extra nutrition assistance to about 6 million low-income, expectant mothers and young children.

But the SNAP program is far larger, costing the federal government about $8 billion a month. State officials are beginning to ring alarm bells about the looming SNAP shutdown. “If SNAP funds are not delivered by the federal government, the State of Illinois does not have the budgetary ability to backfill these critical resources,” the state’s Department of Human Services said in a statement late last week.

Illinois Gov. J.B. Pritzker, the most vocal governor resisting the Trump administration, asked: “Why is it that they can find the money during a shutdown to pay their masked federal agents wreaking havoc in our communities but not help people in need put food on the table? … The very least they could do is preserve SNAP access for low-income families struggling to feed their kids.”

Connecticut officials warned the federal government electronic processing system could also be shut down, which would cut off access to any food assistance dollars that remain on cards from previous months. The Associated Press reported last week that state officials in Minnesota told all counties and Native American tribes not to approve new SNAP applications, and planned to tell recipients tomorrow that monthly benefits will end in November, barring any changes.

Any prolonged shutdown in federal food assistance will have devastating health consequences. Food insecurity and housing insecurity are major contributors to ill-health in the U.S. One in eight Americans depend on food stamps and even $100 billion a year is not enough to meet the need, witness the charity-dependent food banks that exist in every major city in the country and many ex-urban and rural areas. The U.S. spends even less on subsidizing housing than it does on subsidizing food.

Yet both programs have been targeted for cuts by the Republican-run Congress. The One Big Ugly Bill signed into law last July imposed work requirements in the food stamp program for adults aged 55 to 64 and parents with children 14 and over.

Food isn’t the only area where the Trump regime is moving to administer maximum pain in its efforts to reopen the government without negotiating compromises. Last week, shortly after flip-flopping on cutting off Medicare payments to physicians, it announced it would cease offering special assistance to rural hospitals and for telehealth, programs whose funding expired at the end of September. StatNews reports “ground ambulance transport services and Federally Qualified Health Centers could also be affected by the pause in some payments.”

Most of these cuts will have their deepest impact on states run by Republicans. But that doesn’t seem to matter to the Trump administration, which could care less about the collateral damage in its war against anything and everything that smacks of social decency.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

New Report Sharpens Doubt About Medicare Advantage As Open Enrollment Begins

New Report Sharpens Doubt About Medicare Advantage As Open Enrollment Begins

Open enrollment for the over-65 crowd began yesterday with most analysts predicting there will be a sharp dip in the number of seniors who choose privatized Medicare Advantage plans for 2026.

That’s good news for people worried about the program’s fiscal health and the looming expiration of its trust fund, now slated for 2033. The Center for Medicare and Medicaid Services paid MA plans an estimated $84 billion more than it would have had the 54 percent of all beneficiaries choosing MA plans in 2025 — the most ever — remained in traditional Medicare, according to the Medicare Payment Advisory Commission.

Why do experts predict many people will opt out next year? In part, it’s because the three major insurers selling MA plans — UnitedHealth, Humana, and CVS Health’s Aetna — have eliminated hundreds of counties, and in some cases, entire states from their plans.

Despite the enormous profits they earn from MA, insurers complain rising prices and greater utilization are driving up their expenses (true) while the federal government is curtailing reimbursement (false). The Center for Medicare and Medicaid Services final MA payment rule, unveiled last April, showed private health plans will get an effective rate increase of nine pecent in 2026, which is several percentage points above inflation-adjusted economic growth rate.

Disappearing plans is not the only reason why people are abandoning MA. Consumer preference is playing a huge role.

Private insurers are increasingly using prior authorization to curb utilization. Prior authorization is where physicians are required to obtain insurer approval before making specialist referrals, prescribing certain drugs, tests and procedures, and, in some cases, ordering preventive care. This delay and deny strategy (the first allows insurers to earn money on the float; the second simply cuts expenses) is drawing enormous pushback from physicians and patients, so much so that the industry was forced to announce this past summer it would take steps to ease the approval process — by 2027.

The Centers for Medicare and Medicaid Services has also been revamping its “star” rating system, which is one of the few tools elderly consumers have for comparing the quality and outcomes of different plans. Insurers sometimes game the system by combining multiple counties from widely dispersed geographic areas into a single plan for star-rating purposes, which gives a false picture to beneficiaries who happen to live in poor-performing counties included in the plan. Insurers must have 94 percent of its MA members in plans rated 4-star or 5-star before getting a five percent bonus payment.

The revamp is having an impact. For instance, in 2024 Humana had 94 percent of its MA plan members in 4- or 5-star rated plans. The changes instituted by CMS (an agency which so far has escaped the scientific quackery and staff cutbacks Robert F. Kennedy Jr. and Martin Makary have imposed on the Centers for Disease Control and Prevention and the Food and Drug Administration, respectively) reduced its 4- and 5-star share to 25 percent this year, according to a story yesterday in Modern Healthcare. Earlier this week, the U.S. District Court in North Texas rejected Humana’s suit challenging the reduction.

Has Medicare Advantage improved quality?

There is still a substantive debate about whether MA has improved quality for its beneficiaries.

The original idea behind Medicare Advantage, which took off in the early 2000s, was that privatization of Medicare would lead to lower costs since the private sector was, allegedly, more efficient. Proponents of MA also argued that replacing fee-for-service reimbursement as deployed by the government in traditional Medicare with privately managed care would lead to higher quality, greater patient satisfaction and, most importantly, better outcomes.

The first argument is demonstrably false. As numerous MedPAC reports have shown, MA hasn’t saved the government a dime. In fact, over the years it has cost the government hundreds of billions of dollars more.

But have we at least gotten better results from all the extra taxpayer money shoveled out to the insurance industry through privatization? Dozens of studies have been conducted over the years testing that question. Proponents of MA, led by the Better Medicare Alliance, an industry front group, cherry pick the literature to claim MA enrollees have fewer hospital readmissions, fewer preventable hospitalizations and reduce the use of high-risk medications among seniors. Privatization opponents like the Center for Medicare Advocacy are equally adamant that quality in MA is at best no different than traditional Medicare, and in some cases worse.

A September 2022 Kaiser Family Foundation report examined 62 studies published since 2016 that compared MA and traditional Medicare based on measures of beneficiary experience, affordability, service utilization, and quality. The report found MA “outperformed traditional Medicare on some measures, such as use of preventive services, having a usual source of care, and lower hospital readmission rates. However, traditional Medicare outperformed [MA] on other measures, such as receiving care in the highest-rated hospitals for cancer care or in the highest-quality skilled nursing facilities and home health agencies.”

Today, the Commonwealth Fund offered a first-of-its-kind comparison study of Medicare performance in all 50 states and the District of Columbia. While comparing traditional Medicare to Medicare Advantage wasn’t its focus, and its authors caution against using its findings to highlight quality differences between the two approaches to paying for care, the scorecard’s findings did suggest (based on my analysis) that MA delivers outcomes on key quality measures that are at best equal to traditional Medicare, and sometimes worse.

The overall study looked at 31 measures of access, quality, affordability and population health, derived from the records of both traditional Medicare and Medicare Advantage plans. Two of the main quality indicators highlighted in the report were the statewide number of preventable hospitalizations per 1,000 beneficiaries, and what share of seniors on Medicare were prescribed drugs known to be risky or inappropriate for people in their age group.

For the overall score, the study’s authors ranked each state and the District of Columbia for the 31 measures, and then created a composite score. The results were predictable: Vermont, Utah, Minnesota, Rhode Island, Colorado, New Hampshire, Maine and Hawaii were, in order, the eight top-ranked states; starting from the bottom, Louisiana, Mississippi, Kentucky, Oklahoma, Arkansas, Texas, West Virginia and Alabama brought up the rear.

Those results show that the social determinants of health — statewide wealth and income, food and housing security, low unemployment and the like — drive overall health and therefore health care spending in Medicare. That’s not surprising. How well people fare during their working years will usually determine how well they fare in retirement, which in turn determines how much they will cost Medicare and, ultimately, how long they will live.

“Spending doesn’t always align with outcomes,” said Dr. Joseph Betancourt, president of the Commonwealth Fund. “The states that tend to do well in Medicare performance also tend to do well in our other surveys of broader populations.”

But in looking at the two quality indicators highlighted by the study, a different pattern emerges. I ranked the share of each state’s population in Medicare Advantage plans in 2024 (compiled by the Kaiser Family foundation) and compared that to the state’s performance on two quality indicators: preventable hospitalizations and inappropriate drug prescriptions. In the charts below, the numbers in red and purple (the worse five) are states with below average scores (which are higher numbers); the numbers in black are states that did better (lower numbers) than the national average.

These are important measures for evaluating Medicare Advantage performance since preventing unnecessary hospitalizations is precisely what MA managed care is supposed to achieve and inappropriate prescribing is precisely what MA prior authorization is supposed to prevent. The study also measured what share of MA plans in a state used prior authorization, which is shown in the second column in the chart.

The bottom line: States with above-average enrollment in MA plans tend to have higher-than-average rates of preventable hospitalizations. There is no discernible pattern in the rates of inappropriate prescribing between states with above or below average enrollment in MA plans.

For instance, Michigan ranked in 25th or right in the middle of the pack in the overall rankings. It had the highest Medicare Advantage penetration (61.6 percent). Yet its managed care plans, nearly half of which used prior authorization, did not prevent the state from being ranked fifth worst in preventable hospitalizations and three percentage points above the national average in inappropriate prescribing. Ditto for Alabama, which had the second highest MA market penetration, yet ranked among the five worst when it came to preventing unnecessary hospitalizations and inappropriate prescribing.

On the other end of the spectrum, rural states like Vermont and Wyoming had very low MA market penetration and scant use of prior authorization. Yet they scored above average performance on both quality indicators.

Having read numerous studies over the years that compare Medicare Advantage to traditional Medicare, I think it’s fair to say at this point that all the extra money that’s been poured into Medicare Advantage has not delivered to beneficiaries higher quality care or better outcomes. It is, in fact, a waste of money.

I’ll leave the last word to Gretchen Jacobson, the Commonwealth Fund vice president for expanding coverage and access. When it comes to Medicare, the federal government should “set standards for private plans and participating providers” and “incentivize providers to apply best practices and reduce wasteful care.”

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

Democrats Must Address Looming Cost Spike In Private Health Insurance

Democrats Must Address Looming Cost Spike In Private Health Insurance

Here’s the good news. The Democratic Party’s demand that Congress extend the Affordable Care Act premium subsidies in exchange for helping end the government shutdown is fracturing the GOP monolith.

In recent social media posts, Rep. Majorie Taylor Greene (R-GA) articulated what every legislator on the GOP side of the aisle knows but won’t admit. Out-of-pocket costs for ACA plans will skyrocket next year if the enhanced subsidies passed by the Biden administration during the pandemic are allowed to expire.

“This is a major crisis in America,” she said this week on NewsNation, a conservative cable news network. “We’re looking at a massive spike in health premiums. It’s going to crush people. They’re going to have to drop their health insurance. That will put a lot of people in danger of becoming bankrupt with health care bills, with hospital bills,” she said.

Even Donald Trump, ever the prevaricator, has begun toying publicly with opening negotiations with Democrats after Greene made her comments.

But she went further. It is not just the 24 million people on ACA plans who will get hit hard with average premiums more than doubling to more than $1900 a month (before subsidies) without the enhanced premium subsidies. “People with regular or private plans, their premiums are looking to go up a median of 18 percent. That’s brutal,” she said.

Always fast and loose with her facts, Greene’s claim that private health plan premiums will rise 18% is more than double what employer benefits consultants are predicting. But there’s no doubt huge spikes in employer premiums and employee co-premiums are coming. Both will likely to see near double-digit increases.

That’s the issue I want to address in today’s post because it represents a messaging minefield for Democrats, even if they win an extension of the ACA plan subsidies.

Where’s the rest of us?

During September, there was an interesting debate within the Democratic Party about what to demand from the GOP majority before giving them the votes needed to keep the government running beyond September 30th. Progressives wanted to focus on limiting the Trump regime’s flagrant violations of the law and constitution. Centrists, led by Senate Minority Leader Chuck Schumer (D-NY) and House Minority Leader Hakeem Jeffries (D-NY), preferred putting health care — usually a winning issue for Democrats — front and center. The centrist majority won the day.

The political wisdom of the leaders’ decision now seems vindicated. As Jonathan Cohn wrote yesterday in The Bulwark (his post was headlined “The Democrats Are Winning the Shutdown Fight”):

“A big premium spike can be a political nightmare for the party in charge, as anybody who lived through the Obamacare rollout can attest. That’s the whole reason Republicans seem so uncertain about their current position—and why now even MAGA stalwarts like Greene are suggesting Republicans sign on to an extension. If nothing else, that would seem to give Democrats leverage to demand even more…
“Democrats actually do care passionately about making health care more affordable. If the subsidy boost lapses, the higher costs will mean real hardship for many millions, and 4 million more Americans with no insurance at all. Extending the subsidy boost would prevent most or all of that from happening. And insofar as Republicans are bound to support some kind of extension eventually—precisely because the blowback to the spike could be so strong—forcing a deal now, in this high-profile debate, would allow Democrats to claim (legitimately) it was their doing.”

Nowhere in his lengthy article did Cohn discuss the employer-based insurance market, which covers 164 million working Americans and their families. If the Democrats say nothing about their looming health care cost increases, it will be a huge mistake.

Should Democrats win on the ACA issue, it will no doubt be great news for the 24 million Americans whose health insurance comes through plans sold on the exchanges. Just seven percent or about 1.7 million purchasers pay the full cost of their plans. The rest receive subsidies based on income that limit their out-of-pocket premiums. The lowest wage workers pay nothing at all.

For most, the total cost of the plan is irrelevant. The federal government picks up most if not all of any increase in the total cost of the plan.

But that won’t be true for the far larger employer-based insurance market — the half of all Americans whose health plans come through an employer, group or union. Their plans receive no direct subsidy. The employer share — on average about 75 percent of a family plan — is tax deductible as is any employee premium, usually deducted from paychecks. But the employee share paid through co-pays and deductibles is not unless their medical expenses exceed 7.5 percent of adjusted gross income; they itemize deductions; and their total deductions exceed the standard deduction. Even then, the deduction is only the amount over 7.5 percent of AGI.

Both employers and employees will bear the full upfront cost of the expected large increases in premiums on tap for next year. A month ago, Mercer, a leading benefits consulting firm, projected average employer premiums could rise nine percent next year based on preliminary results from its annual survey of nearly 2,000 employers. It predicted actual increases would be closer to 6.5 percent because of steps employers will take to hold those costs in check. That’s still twice the overall inflation rate.

Smaller employers will be hit hardest of all. A recent issue brief from the Kaiser Family Foundation found the median proposed premium increase for 318 small group insurers who offer ACA-compliant plans was 11 percent.

What’s behind rising costs?

Mercer health research director Beth Umland cited the usual suspects for the biggest increase in health care costs since 2010: The high cost of cancer treatments and weight-loss drugs; higher-than-usual price increases enabled by provider consolidation; higher health care worker wages driven by rising inflation in the general economy; and the “buildout of AI-based platforms that help providers optimize billing.”

The KFF brief echoed that analysis. It cited higher prescription drug costs and utilization, rising labor expenses, and overall economic inflation. “Some insurers also note declining enrollment and worsening risk pool morbidity as factors leading to higher projected costs next year,” the brief said.

The daily news in the health care trade press is filled with stories of insurers and providers battling over who should be forced to absorb some of those rising costs. Insurers are increasingly resorting to the “just say no” form of prior authorization and receiving pushback from both providers and patients. Modern Healthcare (where I used to be editor) reported this morning that insurers Aetna and Cigna are imposing their own version of the two-midnight rule (don’t ask) by forcing hospitals to accept out-patient rates for emergency room visits deemed routine care, no matter how long they stay in the hospital.

There’s going to be a lot more of those ER visits next year should the ACA subsidies not be extended, since an estimated four million people are expected to drop coverage. That will force many folks to use hospital ERs instead of primary care physician practices for their routine care. And, given that those dropping coverage will be fairly low income, most will postpone or fail to pay those ER bills, which leads to higher prices for everyone else who uses hospital services. Hospitals invariably raise prices to make up for uncompensated care.

And how will employers mitigate some of those rising costs (thus whittling the expected nine percent increase down to 6.5 percent), according to Mercer? “The survey found that 59 percent of employers will make cost-cutting changes to their plans in 2026 — up from 48 percent making changes in 2025 and 44 percent in 2024,” Umland wrote. “Generally, these involve raising deductibles and other cost-sharing provisions, which can lead to higher out-of-pocket costs for plan members when they seek care.”

In other words, workers will see their out-of-pocket co-pays and deductibles rise sharply in addition to a 6.5% average increase in their co-premiums, which are taken directly out of their paychecks. Workers with chronic health care needs could see their annual medical expenses rise at three times the overall inflation rate — perhaps even into double digits.

Only a tiny share of those increased costs will be mitigated by a Democratic win on ACA subsidies. Nor will a win do anything to help the millions of people who will be thrown off Medicaid, whose uncompensated expenses when they also show up in ERs for routine care will also be reflected in higher private employer/employee insurance bills.

For a majority of Americans, any Democratic Party claim that they “saved” health care by their strong stance during the shutdown negotiations will ring hollow in the face of their still rising out-of-pocket expenses.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

JB Pritzker

Lawless Order: Chicago On The Verge Of Federal Occupation

I awoke this morning in a city on the verge of occupation.

On Monday afternoon, U.S. District Court Judge April Perry, a Biden appointee, refused to do what a Trump-appointed judge did in Oregon: Issue a temporary restraining order preventing the federalized National Guard from occupying a peaceful city. This would be a direct violation of the Posse Comitatus Act of 1878 and a move Gov. J.B. Pritzker, Mayor Brandon Johnson, Police Chief Larry Snelling and state Attorney General Kwame Raoul say is unwanted, unnecessary and unconstitutional.

Judge Perry gave the lawbreaking regime in Washington two days to respond. This gives Trump and his minions the time they need to bring in 700 troops from the Texas and Illinois national guards, a move they’ve been looking to justify for months through constant provocations. Their campaign has led to the arrest of hundreds of local residents, a significant share of whom are U.S. citizens. Over the weekend, it included several politicians attempting to protect their constituents by reminding them of their rights.

The military-style campaign, carried out by masked and otherwise unidentified agents from multiple federal law enforcement agencies, included the unprecedented and now infamous assault on an apartment building in the historic South Shore neighborhood, which lies adjacent to Jackson Park, home of the soon-to-open Obama Presidential Center. About 300 federal agents stormed the five-story building and its fewer than 100 residents in the middle of the night by rappelling onto the rooftop from helicopters, throwing flash-bang grenades, kicking down doors, ransacking apartments and detaining adults and children with zip-ties. Many were U.S. citizens or in the U.S. legally.

“They just treated us like we were nothing,” one local resident told ABC7 Chicago. She was handcuffed, had a gun pointed in her face and held until 3 a.m. before being released. The raid, carried out without warrants, resulted in 37 arrests.

At least some of those detained were children, including four U.S. citizens, according to news accounts. One neighbor told television reporters she saw agents zip-tie the kids. “They was terrified. The kids was crying. People was screaming. They looked very distraught. I was out there crying when I seen the little girl come around the corner, because they was bringing the kids down, too, had them zip-tied to each other.” At least one agent laughed when local residents protested the children’s mistreatment. “He said, ‘Fuck them kids,’” she said.

“Imagine an armed stranger forcibly removing you from your bed, zip-tying your hands, separating you from your family, and detaining you in a dark van for hours,” Pritzker said in the aftermath of the raid. “This didn’t happen in a country with an authoritarian regime — it happened here in Chicago,” he said.

Judge Perry refused to act because she needed time to read the voluminous court filings, according to today’s Chicago Tribune. Though “very troubled” by the Trump regime’s actions, she gave the Department of Justice until midnight Wednesday to respond.

Invasion imminent

The newspaper reports those troops will be moving into the city as soon as today since Gov. Pritzker and local officials have no options beyond the courts for enforcing the law. While a case could be made for using local law enforcement to police the illegal actions of individual federal agents, that would be exactly the type of provocation Trump regime is looking for to escalate its assault on the city.

The militarized presence is not limited to the few neighborhoods making the news. When my wife and I returned to Chicago late Sunday after two weeks away, we were greeted by at least one military helicopter flying low over our mostly white neighborhood along Chicago’s North Side lakefront. A friend reports the federal government also sent military helicopters flying over his mixed, middle-income neighborhood over the weekend. They used searchlights to pan streets, lawns and alleys, no doubt scaring the bejesus out of the local rat population.

The regime’s actions make clear this has nothing to do with immigration enforcement. Their goal is to terrorize the local population, whom, through its votes and elected leaders, have chosen to stand in opposition to the illegal and immoral actions of the Trump regime.

The Trumpists are simultaneously consciously attempting to destroy the local economy. It illegally cancelled an already-approved $2 billion contract for mass transit expansion. The president’s constant lies about the state of crime in this city (“a hellhole” and “the murder capital of the world”) is a deliberate attempt to smear the reputation of the Midwest’s top tourist attraction, especially for foreign visitors.

Early estimates showed foreign tourism was down sharply this summer after returning to pre-Covid levels last year. The drop in Canadian tourists — the single largest group — was an estimated 25 percent, which isn’t surprising given they’ve taken to booing the Star Spangled Banner during sporting events in Canada.

According to the state’s complaint filed yesterday in Judge Perry’s court, the Trump’s regime assault on Chicago is creating “economic harm, depressing business activities and tourism that not only hurt Illinoisans but also hurt Illinois’s tax revenue.” The economies of thriving Hispanic neighborhoods have been especially harmed by the constant presence of ICE agents. Street traffic has been reduced to Covid-lockdown levels since everyone with brown skin is at risk of being detained and possibly arrested for failing to present proper credentials during ICE’s indiscriminate sweeps.

The core of the lawsuit charges the federal government with overstepping its authority and violating the constitution. The “deployment of federalized military forces to protect federal personal and property from ‘violent demonstrations’ that ‘are occurring or are likely to occur’ represents the exact type of intrusion on State power that is at the heart of the Tenth Amendment,” the complaint says. “The deployment of federalized National Guard, including from another state, infringes on Illinois’s sovereignty and right to self-governance. It will cause only more unrest.”

I suspect we will learn first hand the truth of that latter statement in the next few days as more Chicagoans are subjected to the presence of heavily armed soldiers patrolling their previously peaceful streets.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News

ObamaCare Scare

The 'Obamacare Scare' That Forced Government Shutdown

There are many ways to debase a debate and guarantee a government shutdown.

The White House showed its way on Tuesday when Trump posted on social media a deepfake video portraying House Minority Leader Hakeem Jeffries wearing a sombrero while Senate Minority Leader Chuck Schumer says Democrats “have no voters anymore, because of our woke, trans bullshit” and “if we give all these illegal aliens health care, we might be able to get them on our side so they can vote for us.”

The Wall Street Journal editorial page weighed in with a deepfake economic spin to what other media outlets are calling a “vulgar” (Politico), “racist” (The Independent), and “falsely accusing” (New York Times) video. The Murdoch clan-owned Journal claimed that people who took advantage of the enhanced premium subsidies to buy health insurance (the Democrats’ sole demand for giving Republicans the votes they need to avoid a shutdown) did so to avoid paying for “affordable” health care coverage provided by their employees.

“Workers aren’t supposed to receive ObamaCare subsidies if they have access to ‘affordable’ coverage through their employers, but this rule is barely enforced,” the editorial complained. “Many workers could get employer coverage if the enhanced subsidies lapse at the end of the year, which would save taxpayers hundreds of billions of dollars. Don’t believe the Democrats’ ObamaCare scare.”

Its evidence? The paper cited a recent Bureau of Labor Statistics report showing that take up of employer-offered plans is plunging, especially among low-wage workers. Nearly three-quarters of employers now offer health coverage, up from 71 percent in 2019, according to the BLS. Yet just 65 percent took advantage that offer in 2025, down from 73 percent in 2019.

Among workers in the bottom 25 percent of wage earners, take up was just 49 percent this year compared to 61 percent a half decade ago. And in the lowest 10% percent of income, take up was just 34 percent compared to 57 percent in 2019.

Why? “Perhaps because they can now get ObamaCare plans at no cost,” the opinion page speculated.

Let’s take a closer look at what the Wall Street Journal editorial page deems is “affordable” health care coverage that employers offer to their low-wage workers. The average cost of an annual health insurance plan in 2025 was $25,572 for family coverage and $8,951 for individual coverage, according to the Kaiser Family Foundation. The average employee contribution to family coverage was 25% of the total or $6,296, according to KFF. For individual coverage, workers paid 16% of the total or $1,368.

Now let’s take a look at what low-wage households earn. In 2024 (BLS data on household income lags behind publication of monthly and annual wage data) families earning at or below $41,400 a year landed in the bottom 25% of all households. Those in the bottom 10% earned at or below $19,900 a year.

That level of income doesn’t make their employer plans affordable. It makes them prohibitive.

A family at the 25th percentile would be paying for an average family plan fully 15 percent of its annual income for coverage. Better-off families that itemize their deductions (lower wage workers almost never itemize) would be able to take half of that as a tax deduction. A better way to characterize Obamacare subsidies is as one way to help to level the playing field of our inequitable tax code.

Meanwhile, a family in the bottom 10 percent of households would be paying a prohibitive 32 percent of its income for health insurance through their employers. No wonder take up of employer-offered plans among low-wage workers is so low, and was so even before arrival of the Affordable Care Act. When you’re poor, paying your rent, food and transportation bills have a higher priority than buying protection against the possibility you’ll be thrown into bankruptcy should someone in your family might get sick in the coming year.

That’s not something an editorial writer who is paid not to understand the economics of health care will ever understand.

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooz News.

RFK Jr MAHA

Kennedy's MAHA Movement Reveals Itself As Corporate Front

Robert F. Kennedy Jr.’s Make America Healthy Again commission on children’s health reached its ignominious conclusion Tuesday by issuing a final report that failed to mention the biggest threats to childhood ill-health in the U.S.

The final 73-page report, which was accompanied by a 20-page strategy memo, made no mention of:

  • Gun violence, the number one killer of American children under 18;
  • Smoking, a lifelong habit most take up when teenagers; or
  • Global warming, the greatest long-term threat facing the youngest generation.

Mentioning these issues would have required the report call attention to the biggest roadblocks standing in the way of addressing each of these issues. They are, respectively, the Gun Lobby, Big Tobacco and Big Oil & Gas.

Those industries are fervent supporters of the U.S.’s authoritarian headman, Donald Trump. His only consistent political position — one that he requires all his lackeys adhere to — is steadfast support for the nation’s richest and most powerful corporations and individuals, especially those that have given him huge campaign contributions.

Even when it came to addressing the issues that Kennedy claims to care most about, his need to please Trump by giving special interests a pass denuded the final report of any meaningful measures. Those issues include the prevalence of ultra-processed food; chemical food additives; environmental toxins; and excessive use of psychotropic drugs and vaccines. Other than vaccines (last week, his denigration of vaccines led even a few Republican physician-Senators to question his honesty), those are issues that most Americans and unbiased researchers would also like to see addressed.

Yet the final report failed to outline any concrete steps that the Health and Human Services Department, the Agriculture Department or the Environmental Protection Agency plan to take. “A lot of this is nice (but) it’s a report about intentions, not about actions,” New York University professor of nutrition emeritus Marion Nestle told the PBS NewsHour. “How on earth are they going to do these things (when) the word regulation is only mentioned once?”

Many of the deregulatory and budget cutting actions taken by the Trump regime since taking office work directly against the goals outlined in the report. For instance, the Environmental Protection Agency’s research department has been gutted, all but eliminating the agency’s ability to scientifically determine which environmental toxins are causing significant harm to children’s health.

The budget for the Supplemental Nutrition Assistance Program (colloquially food stamps) has been cut sharply, which will reduce food assistance to almost three million children. Rather than taking steps at the federal level to limit the ability of low-income beneficiaries to purchase sugar-laden beverages or salt-heavy snack foods (instead, they plan to offer technical assistance to states that want to do that), the Trump regime is making more children go hungry. Common sense suggests allowing three million kids to go hungry will destroy the health of far more children than allowing parents of kids on food stamps to continue buying soda pop.

The strategy report called on the Department of Education to “help states” reinstitute the presidential fitness test. The DoE is currently being dismantled by the Trump regime.

Also, it claimed HHS’ Administration for Children and Families will “promote greater physical activity” in after-school and summer programs. Meanwhile, Trump’s budget cutters slashed $7 billion to support those programs in June, only to restore a mere $1 billion a month later after widespread protests from educators in both red and blue states.

Perhaps the most curious oversight in yesterday’s strategy report was its turnaround on the chemicals, dyes and other additives in ultra-processed foods (UPFs), a major bête noire for Kennedy and a long-time concern of mainstream nutritionists. The main report’s 7-page section on UPFs contained 75 footnotes. Yet the strategy memo contained just a single action item of little significance: “USDA, HHS, and FDA will continue efforts to develop a U.S. government-wide definition for ‘Ultra-processed Food’ to support potential future research and policy activity.”

“What this says to me is that the first report was written by MAHA,” Jerold Mande, an adjunct professor of nutrition at the Harvard T.H. Chan School of Public Health and a former senior policy official for nutrition in the Bush, Clinton, and Obama administrations, told Time magazine. “The second one, the White House let industry lobbyists write it.”

Merrill Goozner, the former editor of Modern Healthcare, writes about health care and politics at GoozNews.substack.com, where this column first appeared. Please consider subscribing to support his work.

Reprinted with permission from Gooznews

Labor Day weekend shootings across Chicago

Where Does Chicago's Murder Rate Actually Rank?

The New York Times released a story on Wednesday afternoon about crime rates in various cities. Its headline? “Crime Festers in Republican States While Their Troops Patrol Washington.” It pointed out that cities like Kansas City, St. Louis, and Springfield, Missouri; Birmingham, Alabama; Cleveland, Dayton and Toledo, Ohio; Tulsa, Oklahoma; Memphis and Nashville, Tennessee; Houston, Texas; Little Rock, Arkansas; Salt Lake City, Utah; and Shreveport, Louisiana have crime rates comparable to Washington’s, where federal troops have been patrolling for the past few weeks.

Why isn’t the Times taking a close look at Chicago, which faces a federal invasion? The truth is that my home city is on pace to have its lowest murder and violent crime rate in four decades. Where does it rank in terms of cities when it comes to murders? It turns out Chicago doesn’t even make the top 20. How about cities in Republican run-states? Eleven out of the top 15 have Republican governors.

This list comes from Newsweek magazine (data reflects murders per 100,000 population; cities in bold have Republican governors):

  • Birmingham, Alabama (58.8)
  • St. Louis, Missouri (54.1)
  • Memphis, Tennessee (40.6)
  • Baltimore, Maryland (34.8)
  • Detroit, Michigan (31.2)
  • Cleveland, Ohio (30)
  • Dayton, Ohio (29.7)
  • Kansas City, Missouri (27.6)
  • Shreveport, Louisiana (26.8)
  • Washington, D.C. (25.5)
  • Richmond, Virginia (24.2)
  • South Fulton, Georgia (22.2)
  • Cincinnati, Ohio (21.8)
  • Louisville, Kentucky (21.7)
  • Indianapolis, Indiana (20)
  • Oakland, California (18.6)
  • Albuquerque, New Mexico (18.4)
  • Montgomery, Alabama (18.1)
  • Minneapolis, Minnesota (18)
  • Lancaster, California (17.7)
  • Little Rock, Arkansas (17.6)
  • Hartford, Connecticut (17.6)
  • Chicago, Illinois (17.5)

Of course, facts do not matter to the Trump regime. When the president posted on Truth Social that Chicago is the “murder capital of the world,” it wasn’t even close to the truth.

Reprinted with permission from Gooz News.