By George W. Chapman
Whether or not you are covered by your employer or purchase your insurance as an individual, by now you should have received a notice summarizing the changes for 2027. In some cases, you could be notified your plan is exiting the market so you will have to pick a new plan. If you decide (or are forced) to change plans, you must do so by mid-December. I’ll highlight the changes to my plan, an example. First, it is being offered again. My maximum out-of-pocket responsibility increases $600 from $9,250 to $9,850. My in-network copays remain at $10 for primary care and $50 for specialty care. I checked the plan website to be sure my primary and preferred specialist are still participating — don’t assume your docs are. The copay for out-of-network docs increased from $55 to 40% of office charges. So, a $300 office charge means a $120 copay. Hospital copays jump from $407 a day (up to six days) to $460 a day (up to only five days). The biggest increase is for out-of-network hospitals at 30% of charges. If your circumstances require you to use an out-of-network hospital be sure your plan approves. If all of this seems confusing and expensive, it is. There are independent insurance specialists who can assist you at no charge. They are paid by the plan you eventually choose. Good luck.
AI in Billing
The battle between hospitals seeking to maximize revenue to, in many cases, remain open and insurers seeking to lower expenses and remain profitable continues as both sides deploy artificial intelligence in billing. A study by Blue Cross Blue Shield found artificial intelligence driven billing by hospitals added nearly $1 billion in additional costs the last two years without any evidence of changes in the care provided. And 60% of hospitals use AI to scan lab reports to identify a secondary diagnosis which can result in higher reimbursement for the hospital. Hospitals argue they have been undereporting acuity levels for decades and AI allows them to bill accurately. What are we to do? Hospitals face escalating costs so they need to accurately capture any source of revenue to remain viable let alone open. Insurance companies, attempting to control costs, will simply pass on the added “expenses” in the form of higher premiums, higher deductibles, higher copays and possibly smaller networks. Unless things change drastically, there is no end in sight to this cost spiral.
Band-Aids Aren’t a Solution
Offering a $500 rebate to those purchasing their insurance via the Affordable Care Act exchange is frankly a drop in the bucket. Especially since it goes only to the less than one million people who paid 100% of their insurance premium on the exchange. People who received a tax subsidy based on income or those most in need, are not eligible. The average annual premium on the exchanges for a family of four is about $2,000 a month or $24,000 a year. Who can afford that? $500 is $500 but it really doesn’t solve the affordability crisis in healthcare. $500 covers a whopping one week of insurance and the premiums will only be higher next year. Twenty-three million people lost their subsidized premiums this year. The $90 rebate being offered to 20 million seniors for their Part B (physician) premiums is another Band-Aid that won’t solve the problem or make a difference. The average monthly Part B premium, deducted from monthly Social Security checks is about $200 a month or $2,400 a year. Again $90 is $90 but I’m sure your average senior is not leaping in the air shouting “yippee!” It’s time to stop the useless (political) Band-Aids and find a cure. Throwing some cash around isn’t a solution.
Healthcare Employment
When the job growth reports come out, you can bet healthcare leads all industries, (The impact of AI on all industries remains to be seen.) In the last 12 months healthcare jobs increased by 372,000. If you’re looking for a career change, physician offices, outpatient clinics, nursing homes, hospitals, home health agencies and other ancillary providers are hiring. Experts say the increase reflects our aging population and increase in chronic illnesses that often come with living longer. But are we living longer? The average global life expectancy is 74 and it hasn’t really changed that much. Where do we rank compared to other countries? At an average expectancy of 80, we rank 62 among 234 countries. So. our “bang for the buck” isn’t good. The leaders in life expectancy (for far less money) are: Morocco 87; San Marino 86; Hong Kong; 86, Japan and South Korea 85. The shortest life expectancy is Nigeria 55. Wars, plagues, uncontrolled disease outbreaks, lack of vaccines, provider shortages, shaky governments and food and shelter insecurities will impact a country’s life expectancy.
MAHA in Rural America
A poll of more than 2,000 rural voters conducted by KFF and Associated Press revealed that 80% of respondents feel Make America Healthy Againpolicies have had a negative or no impact on the health in their communities. Physician shortages (35% of respondents) and hospital closures (50% of respondents) lead the way. Both have been exacerbated by Big Beautiful Bill cuts to Medicaid. Higher food prices and insurance premiums have overwhelmed any perceived MAHA improvements.
Measles Outbreak
As of this writing, with three months left in this year, there have been almost 4,000 cases of measles. Something unheard of just a couple years ago. The CDC predicts there could be in excess of 5,000 cases this year. So far, Pennsylvania leads the way with more than 1,000 cases. The CDC has been slow on reporting deaths. Ninety-five percent of measles cases are among the unvaccinated and 20% of cases require hospitalization. Per the DOH, the measles, mumps, and rubella vaccine (MMR) provides 97% lifetime protection. Measles can cause problems throughout an adult’s life as the immune system is compromised. It should be no surprise that 50% of pediatricians are now refusing to care for unvaccinated children. Why are we going backwards!
Behind the Scenes
The Medicare drug negotiating team started under the Biden administration has quietly saved, so far, $18 billion for Medicare and $2 billion in out-of-packet savings for beneficiaries. This has been accomplished by negotiating with little to no fanfare or credit 25 high drug utilization prices over just two years. Each year moving forward 10-15 more drugs are up for negotiation. Unlike the highly publicized and minimally effective Band-Aids developed by the likes of TrumpRx or Mark Cuban’s Cost Plus, this is as close as we have gotten to solving our high-cost healthcare system.