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Category: CMS

  • Medicare Policy Shouldn’t Be Made in the Shadows

    Medicare Policy Shouldn’t Be Made in the Shadows

    As a rheumatologist, I treat rheumatoid arthritis (RA) and other complex autoimmune diseases. If you have or happen to develop one of these diseases, I am thankful that science has delivered amazingly effective targeted therapeutics and biologics in recent decades. While highly effective, these treatments come with a high economic cost, so I have grown accustomed to daily battles with commercial insurance plans to get working-age patients the treatments they need. While horror stories abound regarding commercial insurers, Medicare has traditionally been a more predictable partner for my older patients. Medicare reimbursement is low — an issue worthy of a separate commentary piece — but comes on time, typically without the hassle and administrative delays of prior authorizations, assuming we use our therapeutics within FDA-approved dosing and indications.

    On top of these existing challenges here in the Midwest, providers recently won a battle we did not expect to have to fight with a Medicare administrative contractor (MAC). The story deserves scrutiny from legislators and regulators nationwide. 

    Medicare beneficiaries rightly assume, as have I, that policy spells out the services they are entitled to receive. Lawmakers in Congress establish patients’ benefits in law, while the Centers for Medicare & Medicaid Services (CMS) develops the national rules and policies to implement them. MACs fit into this process by administering those rules regionally (with some discretion), but they are not supposed to privately create new substantive conditions of payment.

    Recently, the MAC overseeing Kentucky and Ohio began auditing and denying claims for intravenous Orencia, a biologic drug used to treat RA, citing a “lack of medical necessity.” The policy affected more than a hundred patients who had mostly been on Orencia for a decade or more. These patients were forced to stop or delay treatment or switch therapies, which resulted in serious RA flares. MAC administrators had decided that most patients on intravenous Orencia, covered under Medicare Part B, should instead receive subcutaneous Orencia, covered under Medicare Part D and often at substantially higher out-of-pocket cost. 

    The decision was made without a formal notice-and-comment process. In fact, this requirement does not even appear in the Medicare guidance cited for this decision. Worst of all, it effectively forced dozens of patients off a life-changing therapy.

    Thanks to outreach from clinicians, national advocacy organizations, angry patients, and congressional representatives, this policy was walked back. Or at least, we think so. There was no announcement of a reversal. Instead, the MAC covering Kentucky and Ohio quietly revised a fact sheet on its website, removing language that preferred subcutaneous over intravenous dosing. 

    This whiplash has been devastating to my own small clinic, however, as the MAC continues to withhold the equivalent of roughly three payrolls’ worth of payments for treatments we rendered in good faith during this period. They have also not answered repeated inquiries about whether denials issued under the now-removed standard will be reversed. 

    This situation exposed several problems that need to be addressed before this happens to other MACs, Medicare beneficiaries and clinicians:

    1. The current system allowed one medical director’s opinion to acquire the force of Medicare policy without an effective check. This violates the Supreme Court’s decision in Azar v. Allina, which limits the government’s ability to create substantive Medicare payment standards through informal guidance. Yet it still took months of work, worry, and countless hours distracted from providing clinical care to get the issue elevated to a level where the policy was reconsidered. 

    2. There is inadequate accountability and little transparency within MAC operations. After an initial call with the MAC medical director to raise this issue, we went for weeks with response and no clue as to where our appeal stood. Providers didn’t know how to “correctly” care for our affected patients. When the disputed language did quietly disappear from the fact sheet, there was no public explanation, formal announcement, or directive regarding claims already denied. 

    3. There is no clearly identified chain of command to move a critical issue of patient harm from a regional MAC to CMS. As an experienced advocate, I leveraged my relationship with my congressional representative and the American College of Rheumatology to elevate this issue to CMS, but what if I hadn’t had those relationships? Our system should not require physicians to become experts in Medicare law and policy just to ensure the Medicare system follows its own rules.

    Medicare beneficiaries deserve better. While in this case we’ve been able to protect access to intravenous Orencia, this experience exposed flaws that extend far beyond one drug or one MAC contractor. We should all be concerned that MACs are increasingly making unilateral decisions that negatively impact patient access. Medicare policy should be transparent and include appropriate notice and stakeholder input. And when a contractor gets it wrong, there should be a clear and rapid way to stop the harm to patients, their relationship with their doctor and the doctor’s practice. A patient’s access to Medicare-covered care should never depend on whether their physician can find someone in Washington willing to intervene. Something must change.

    Author bio:

    Dr. Chris Phillips is an American College of Rheumatology leading rheumatologist and owner of Paducah Rheumatology.

    Photo: Stas_V, Getty Images

  • AI, Tech Leaders Are Lobbying Trump Health Officials in a Government-Run Chat Room

    AI, Tech Leaders Are Lobbying Trump Health Officials in a Government-Run Chat Room

    A cadre of elite techies, financiers, and high-level Trump administration officials have spent a year quietly charting an extraordinary and rapid campaign to persuade Americans to use apps and other artificial intelligence-powered tools to manage their healthcare and medical records.

    As that campaign has unfolded, administration officials have granted tech companies an unusual opportunity to nudge the nation’s health department toward a loosely regulated future for AI health apps in which the government reimburses them for services as it does medical professionals.

    In February, federal health officials invited those businesses — including tech giants Microsoft, Anthropic, OpenAI, Apple, and Google — to a listening session on conversational AI products for patients, such as chatbots. Representatives from at least 35 industry organizations attended the meeting held by the Food and Drug Administration, which is responsible for regulating health apps as medical devices. Companies were prompted in advance to explain their AI products and how they access patients’ sensitive medical information.

    But the meeting did not appear on the FDA’s public calendar or regulatory notices, nor was the public invited. Rather, the invitation for a select group to help shape federal policy governing AI in healthcare was extended in a chat room on the messaging service Slack.

    “This is a great opportunity to support HHS’ goals and share your state-of-the-art understanding of safe Conversational AI development and monitoring to help FDA shape future guidance,” CMS senior policy adviser Morgan Taylor wrote in the Slack workspace.

    The Centers for Medicare & Medicaid Services has not formally announced the chat room through federal regulatory channels, though CMS officials have talked about it at industry conferences. Legal experts said the chat room resembles a federal advisory panel, which would be required to operate in public view.

    KFF Health News reviewed thousands of Slack messages, meeting transcripts, and video recordings that reveal how the Trump administration has granted the industry a direct line to top government officials — including former head of the Department of Government Efficiency Amy Gleason.

    The conversation took place behind the scenes as federal health officials publicly worked to integrate AI and other technology into nearly every aspect of healthcare, a plan they’ve branded the “Health Technology Ecosystem.”

    “We wanted to give industry a chance to play in the sandbox of government-supported healthcare,” CMS Administrator Mehmet Oz said in September at the public launch of an initiative that allows health apps to bill Medicare for AI services such as wearable device tracking. Last week, Health and Human Services Secretary Robert F. Kennedy Jr. delivered an enthusiastic endorsement of AI in healthcare, claiming it is “much better informed than any doctor in the country.”

    Meanwhile, HHS staff even promised that a recently launched Medicare App Library would serve as a lucrative pipeline for those businesses to get new users. The library’s webpage currently promotes only two dozen commercial apps to millions of American seniors and those with disabilities.

    As Trump officials sell it, Americans will get easier access to their medical records so apps can swiftly provide health or wellness advice. In practice, however, so will the tech companies.

    Doctors, meanwhile, are increasingly worried about how patients use and share their medical records with the nascent technology.

    “Some of these tools just aren’t ready for primetime,” said John Whyte, CEO of the American Medical Association. “We don’t have enough data about them. We don’t understand how they work, how they’re using the information. There’s no liability if these tools get things wrong.”

    CMS officials declined to answer several questions about the Slack workspace, including about its legality.

    “CMS is focused on giving Medicare beneficiaries greater access to their health information and useful digital tools while promoting an open, interoperable healthcare system,” Gleason, now chief product officer for the newly created Office of Health Technology and Products at CMS, wrote in an emailed statement. “The Health Technology Ecosystem is an open, voluntary technical collaboration. CMS will continue working with patients, providers, payers, technology organizations, and other stakeholders to make health information more accessible and useful to the Americans it serves.”

    The FDA did not respond to a request for comment.

    The Conversation Begins

    The behind-the-scenes effort to funnel more Americans to AI-powered health apps began in August 2025 in the Slack workspace.

    “Welcome all!” Gleason wrote. “Please be sure to read the Code of Conduct and see the Channel list as well to help you find channels that are relevant to you.”

    Gleason is best known for serving as the acting administrator of Elon Musk’s Department of Government Efficiency, as it gained access to millions of Americans’ sensitive personal and financial data, including at the Social Security Administration.

    As her work with DOGE wound down last year, Gleason welcomed a variety of tech leaders, investors, and entrepreneurs to the chat room.

    Documents have been reproduced from the CMS Health Tech Ecosystem Slack and highlighted by KFF Health News.

    The Slack workspace’s participants include representatives from major digital wellness companies like Oura Health, AI companies like Palantir, and investment outfits like 8VC, a venture capital firm associated with Kennedy’s son Finn. While the Slack’s member count has ballooned to 1,700 over the past year, only a handful of patient advocates, doctors, and hospital representatives are in it.

    The code of conduct Gleason shared on Slack in August 2025 documented that CMS had quietly established a technology working group.

    The document also set ground rules for the Slack workspace, noting that the group does not constitute an “advisory committee,” nor would it be used “to obtain advice or recommendations for HHS, CMS, or any HHS/CMS officials.” The code also advises that federal employees “are prohibited from endorsing any product, service, or enterprise.”

    Joseph Daval, a former FDA lawyer who is now a research specialist at Harvard Medical School, reviewed messages from the Slack workspace at the request of KFF Health News. He said the chat room in some ways resembles a federal advisory committee — an independent panel that can be formally stood up by an agency head, Congress, or the president to ensure agencies act in the best interest of the public rather than industry.

    The law on advisory committees “was passed in part out of a concern about interest group capture, about anticompetitive capture of agency policymaking, about corruption,” he said.

    Daval said the chat group looks like a committee, with members interacting with one another and building consensus on preferred courses of action.

    If it were a formal advisory committee, though, Daval said, it would be subject to certain “membership requirements having to do with independence and fair balance.”

    A ‘Sales Engine’

    Over a series of video calls, CMS officials promised tech leaders participating in the Slack workspace that the agency would promote their health apps.

    Jacob Shiff, the chief AI and technology officer at CMS’ Innovation Center, told industry representatives in a Zoom meeting in February that he hoped the agency’s work would be a “sales engine” for the health apps.

    “We’re going to have a directory of all the organizations,” Shiff said in a video recording reviewed by KFF Health News. “The people on this call who hopefully will have amazing solutions that work will be the winners, and you have every incentive to obviously drive down your costs so you can be extremely profitable and scale. So hopefully we’re selling — or enabling you guys to thrive.”

    This video recording was captured and excerpted by KFF Health News before it was removed from public view. 

    A recording of the call had been publicly available through a Google Drive link but was made private the day after KFF Health News asked about comments made during the meeting.

    CMS did not respond to queries about how the agency has decided which AI-powered health apps appear in the Medicare App Library or why federal employees have promised to promote the products.

    Days before publicly launching the Medicare App Library, CMS officials promised AI tech leaders during an informal meeting that the new webpage would become an important distribution channel for health apps because Medicare enrollees would place trust in products listed on the CMS website.

    “If medicare.gov is promoting it, for lack of a better word, then yeah, it would be an app that I would trust and explore,” CMS’ Taylor said during the April 7 meeting, channeling enrollees, according to a transcript of the call.

    The Medicare App Library’s webpage encourages older and disabled Americans to manage health conditions such as obesity, cancer, or diabetes using two dozen AI-driven apps developed by some of the world’s largest corporations, including Microsoft and Google. Many of the apps promise in their product descriptions to give insight, perform analyses, or develop plans that will help patients lose weight or manage diabetes.

    CMS officials have suggested to tech representatives during at least two meetings this year that those apps will be prioritized for a new agency program that reimburses companies for AI chatbot advice or wearable device tracking, according to video recordings.

    CMS has not publicly divulged all the criteria it uses to decide which apps are listed in its library, but the webpage promotes apps still in their infancy.

    Among them is Slothwise, a health app launched this year from a San Francisco apartment by a young, self-described biotech entrepreneur and triple citizen of Russia, Israel, and the U.S. The app says it “knows your whole health” by analyzing medical records and tracking health data for $9.99 a month. It has been reviewed on the Apple and Google app stores only a handful of times.

    “I trusted slothwise with my health info because it was endorsed by medicare,” one reviewer wrote in a Google review in August. “Connecting info was smooth and I learned a lot about my health.”

    In a statement, Slothwise CEO Sofia Sigal-Passeck did not answer questions about the size and medical expertise of her current team, nor about the availability of a doctor to consult with patients who use the app. The app, she said, is only “informational” at this time.

    “I’ve spent years building at the intersection of AI and complex biological data,” Sigal-Passeck wrote in an email. “A small team is not the same thing as an inexperienced team. Slothwise is built by physicians, PhD researchers and engineers.”

    ‘No Regulation, No Rulemaking’

    What’s often less clear — and buried deep in lengthy privacy policies — is that these apps are tapping into the intimate details of patients’ medical records to fuel their AI-driven analyses.

    Tech vendors have lobbied the government to treat these apps, once they are vetted and authorized by a third-party organization, like a patient requesting records. That position gives apps sweeping access to pull sensitive health data from the national network through which providers electronically exchange medical records, called the Trusted Exchange Framework and Common Agreement, or TEFCA.

    A small but influential group of those tech company executives directly made the case to federal health officials during a formal meeting in May, arguing that when health apps request medical records they should be treated as if they are standing “in the shoes” of a patient.

    On Slack, tech vendors have lobbied for a “frictionless pathway” for verified users, after they’ve consented once, that allows the app to gain limitless access to patients’ medical records from the TEFCA network.

    Ryan Howells, a healthcare management consultant who lobbies for a Washington, D.C.-based digital health tech organization called the CARIN Alliance, has spearheaded an effort for patients — vis-à-vis apps — to more easily access medical records. He has regularly noted in Slack that health apps accessing TEFCA must be vetted by a third-party organization — one of which he sits on the board of — and agree to a code of conduct, developed by the alliance he lobbies for.

    “What more can you do to have trust in these apps?” he wrote in a March Slack message, responding to concerns about how much patient consent is needed for apps to access medical records on the network.

    Kristen Valdes, the CEO of b.well, a company that also connects apps to the TEFCA network, made a similar argument.

    “My opinion is that we need to stop protecting patients from themselves,” she wrote in the same message thread. “Full stop.”

    Howells did not respond to an emailed list of questions from KFF Health News. In an interview, Valdes told KFF Health News that her comment reflected her frustration at the “paternalism” of the healthcare system, which she said has historically made it difficult for patients to access their records. Although, she said, “there are going to be good and bad apps.”

    Other tech leaders worried in Slack about the approach.

    One startup founder cautioned the group to think about the pitfalls of giving health apps broad leeway to pull medical records.

    “We might all be good, honest actors here but security & privacy systems have to be designed around the presence of malicious actors – especially if we want this system to scale up to thousands of apps,” wrote Jason Kulatunga, who runs Fasten Health, a medical records management platform.

    Gleason, the CMS official, has publicly championed the vision shared by Howells and Valdes. In her speeches, she frequently urges doctors to accept patient medical records directly from apps and calls on them to “Kill the Clipboard,” also the title of a 2025 white paper co-authored by Howells that urges doctors’ offices to abandon paper records.

    Last month, Gleason spoke to a crowd gathered at a swanky hotel in Washington for an event hosted by the MAHA Institute, a think tank that supports Secretary Kennedy’s agenda. She laid out her work with tech companies over the past year as she discussed the Trump administration’s efforts to make medical records more digitally accessible.

    As she told it, more Americans can now download an app and access their medical records.

    “Once you’ve verified your identity you can just click a simple button and say, I’d like my medical records into whatever app I choose,” Gleason said.

    She continued: “That was all done just — no regulation, no rulemaking — just by challenging industry to work together.”

  • Opinion: How CMS plans to fix a major flaw in the 340B drug discount program

    Opinion: How CMS plans to fix a major flaw in the 340B drug discount program

    By Casey B. Mulligan

    Oct. 8, 2026

    Mulligan is the chief economist and chief regulatory officer at HHS.

    Some Medicare patients owe more in coinsurance than the hospital paid for their drug. That arithmetic sounds impossible. It is a consequence of the 340B drug discount program and Medicare’s payment formula. Now the Department of Health and Human Services, where I work, is proposing to narrow that gap.

    Congress created the 340B drug discount program in 1992 to financially support safety net hospitals that serve low-income patients. Drug manufacturers must give them steep discounts. But Medicare, Medicaid, and commercial insurers generally reimburse them at the full amount, allowing these hospitals to keep the spread above the discounted purchasing costs.

    A new report from the Department of Health and Human Services shows other unintended consequences of this well-intended program. The spread grows with the price of the drug. It therefore rewards hospitals for using more and costlier drugs and makes physician practices and infusion clinics more valuable after a 340B hospital acquires them. The patient’s treatment needn’t change. The owner and billing site do.

    The 340B program has exploded: Eligible drug purchases rose from $12 billion in 2015 to $81 billion in 2024, mostly at hospitals, as shown in the report. Those purchases are now larger than net Medicare Part B and Medicaid drug spending overall and, among public prescription drug programs, are smaller only than Medicare Part D.

    A 340B hospital that buys another hospital or a physician practice can register more off-campus clinics and contract pharmacies and capture more spread. Hospital off-campus clinic sites grew from about 7,000 in 2013 to more than 34,000 in 2023, often in neighborhoods that are wealthier and better-insured than that of the parent hospital. Contract pharmacies grew from roughly 1,300 in 2010 to more than 31,000 by mid-2026, dominated by the largest chains.

    With greater bargaining power after acquisitions, hospital systems can negotiate higher commercial prices for health care services, which can in turn raise premiums. Newly acquired hospital outpatient sites can also add facility fees to non-drug services. The effects of 340B show up as larger, more expensive hospital systems and a bigger bill for patients, employers, and taxpayers. The program’s ripple effects contribute to the broader problems facing the U.S. health care system.

    Medicare payment for Part B drugs is typically based on average sales price (ASP). Beginning in 2018, the first Trump administration narrowed the spread in Medicare by paying hospitals for 340B drugs’ ASP minus 22.5% rather than the usual statutory standard of ASP plus 6%, based on an earlier estimate of their average minimum discount.

    Overall outpatient drug payments rose nearly 15% a year from 2015 through 2017. Once the lower rate was fully in effect, inflation-adjusted payments largely plateaued. Payments for the affected 340B drugs held near $7 billion from 2019 through 2021. It is clear that Medicare payment policy influences outpatient drug spending.

    The Supreme Court ruled in 2022 that HHS couldn’t vary payment rates by hospital group without first conducting the acquisition-cost survey required by statute. The court didn’t find that hospitals were economically entitled to the markup. It found that HHS lacked a procedural prerequisite. After the lower rate ended and ASP plus 6% returned for these drugs, annual payments for the affected drugs rose from $7.1 billion in 2021 to $10.7 billion in 2023 — a $3.6 billion increase. Overall outpatient drug payments rose from $14.3 billion in 2021 to $17.6 billion in 2023.

    Restoring the higher rate meant paying hospitals more for the same drugs. The $3.6 billion increase combines that direct payment effect with induced changes in hospitals’ dispensing quantities and drug manufacturers’ underlying prices. The larger spread also strengthens hospitals’ incentive to choose costlier drugs and move treatment into 340B billing sites.

    Off-campus hospital departments benefited too. From 2021 to 2023, payments for their affected 340B drugs rose about $800 million even as claims fell and the number of beneficiaries remained similar. Although these amounts do not tell us how many practices hospitals acquired because of the markup, they indicate the additional financial incentives for acquisitions.

    On April 18, 2025, President Trump directed HHS to obtain the cost information the statute requires. CMS surveyed hospitals from January through April 2026 and has proposed paying for affected 340B drugs at ASP minus 33.4% in 2027. CMS estimates that Medicare drug payments would fall by $4.55 billion in the first year and beneficiary drug copayments by $1.15 billion.

    For a drug with an ASP of $1,000, a beneficiary’s standard 20% coinsurance would fall from $212 to $133.20. The prescription hasn’t changed. The patient’s share of the hospital’s bill has. Narrowing the spread also weakens the incentive to steer patients toward costlier drugs and to acquire physician practices and infusion clinics — the very behaviors that have made care more expensive.

    There’s an important lesson here. A small, well-intended discount for safety net hospitals became a large institutional subsidy with expensive unintended consequences. Under the proposed rule, hospitals would still receive their 340B drug discounts. What would change is Medicare’s payment for those drugs at affected hospitals. Congress provided for a survey of hospitals’ acquisition costs, and CMS says its proposed rate would “more accurately align Medicare payments with hospital drug acquisition costs.”

    Medicare patients should not pay coinsurance as though the discount did not exist.

    Casey B. Mulligan is the chief economist and chief regulatory officer at HHS.

  • Medicare Is More Broken Than We Thought

    Medicare Is More Broken Than We Thought

    Note: “An Arm and a Leg” uses speech-recognition software to generate transcripts, which may contain errors. Please use the transcript as a tool but check the corresponding audio before quoting the podcast.

    Please note that this transcript may include errors.

    Dan: Hey there. In the first week of October last year, 2025 — a whole bunch of senior citizens in Minnesota got a letter with some bad news. 

    Amy Hockert: A lot of changes coming in 2026. We know that at minimum 160,000 of you, absolutely have to pay attention to this,

    Dan: Their health insurance through Medicare Advantage was going away. 

    Erin: I was so mad. I was like, “No. Now what do I do?” And I look at my husband and said, “Now what?” “

    Dan: Folks like Erin– who lives in small-town Cambridge,Minnesota–  were going to have to find a new plan by the end of Medicare’s annual open enrollment period, which would start in a couple weeks.

    Up until now, Erin had been on a plan from a local nonprofit insurance outfit called U Care.

    UCare offered some of the most generous and affordable plans in Medicare Advantage — the version of Medicare operated by private health insurance companies. 

    But U Care was going belly up.

    FOX 9: The collapse of UCare after 40 years in Minnesota has been swift and stunning.

    Dan: Callers jammed the phonelines at Minnesota’s Aging Pathways hotline — thats the state agency that helps people with Medicare. Kelli Jo Greiner runs it.

    Kelli Jo Greiner: I don’t know any other way to describe it other than total chaos. Our phones were ringing off the hook.

    Dan: Meanwhile, in the Twin Cities suburb of Maple Grove, an insurance broker named Alison Ebert had been getting ready for her busy season, making appointments with her usual clients.

    Alison Ebert: October 1st through October 14th, I always set my appointments with my clients. I always joke I get paid in cookies and coffee because I go to their homes, we sit down. I know their families, I know their kids, their grandkids

    Dan: The day open enrollment started, she got 47 calls — from people she’d never met. People whose coffee and cookies she’d never tasted.  That was new. 

    And more would call. Because more letters were starting to go out.

    Not just from U Care. Other health insurance carriers were dropping out of the area. UnitedHealthcare, BlueCross, Aetna, Humana — all canceled Medicare Advantage plans in counties all over the state. Three counties were left with no Medicare Advantage plans at all. 

    And… this wasn’t just something that was just happening in Minnesota. Almost 3 million seniors across the country had plans in 2025 that would stop being offered to them in 2026.

    And that’s because at their headquarters, insurance companies had done their calculations, assessed their risks, and decided that offering plans to those people would no longer be profitable enough. So, seniors from Maine to California saw the number of available Medicare Advantage plans shrink by the dozen — leaving a lot of them confused, and with fewer, often worse and more costly health insurance options. 

    It’s part of a big new trend — these disappearing acts  have been increasing in recent years, and insurance companies have already signaled that more are coming. Major insurers have already announced intentions to dump plans that currently cover more than two million seniors. 

    We’ve spoken with folks in a dozen states — in rural places like Vermont and North Dakota, and in states with rural and urban centers like Maryland and Minnesota — about how it all went down last year — and what we can take away for this year.

    My colleague Emily Pisacreta and our awesome summer intern Lynn Barbera made those calls. And Emily, you called that experience “eye opening.” 

    Emily: Uh, yeah. We already knew from previous reporting that people had problems with Medicare Advantage. At first this story sort of seemed like one more thing people on Medicare Advantage had to worry about. But it turns out to be more than that. What happened last year — and is about to happen again this fall — showed us big problems, problems that affect everyone who’s on Medicare — or hopes to be one day. There are layers to this. 

    Dan: And we’re gonna peel them back. Get ready for a big dose of Medicare.

    This is An Arm and a Leg, a show about why health care costs so freaking much and what we can maybe do about it. I’m Dan Weissmann, I’m a reporter and I like a challenge. So our job on this show is to take one of the most enraging, terrifying, depressing parts of American life and to bring you a show that’s entertaining, empowering and useful.

    Emily, a while back, we looked at problems with Medicare Advantage. How about we do a little recap?

    Emily: Yeah. 

    Dan: We were taking our first deep look at Medicare itself, and as we said then, it kind of blew our minds. 

    Emily: Before we did that story, I was under the impression that you wake up on your 65th birthday and never have to pay a medical bill again, never have to deal with health insurance companies again. In fact, that’s the dream of Medicare For All. 

    Dan: But it’s not the reality of Medicare as it exists. For one thing, signing up means making a dizzying number of choices. 

    And you basically never escape private insurance companies. No way. Turns out, they run a lot of Medicare — so you could see dozens of different plans offered by different companies. 

    But here’s the most important part: You have to choose between what’s now called Traditional Medicare — run by the U.S. Government — and Medicare Advantage plans, run by private insurance companies. 

    And they both have downsides. 

    Traditional medicare doesn’t cover everything. For outpatient medical care — for doctor visits, outpatient procedures, infusions, physical therapy, X-rays and MRIs, you name it — Medicare only pays 80 percent of the bill.  

    And those other things can get so expensive — the remaining 20 percent can run to thousands of dollars that most seniors don’t have. 

    If you want that covered — and, I mean, you do — you actually have to buy a “supplemental” policy — people call them “Medigap” plans. They’re offered by private insurance companies. And you pay a premium. 

    Oh, and did I mention that you’re already paying a premium to the feds for your Medicare? Yep. Exactly how much depends on your financial situation, but most people pay just over 200 bucks a month.

    Medigap premiums – to the private companies – are on top of that. They vary a lot — by what plan you pick, and by where you live — but the average is another two-hundred and some every month. And that number goes up every year. 

    So you’re paying all that but then you’ve still got another gap. Vision, dental, and hearing. Traditional Medicare doesn’t cover them at all. So Medigap plans generally don’t cover them either. 

    The dark joke is that eyes, ears and teeth are “luxury organs”

    Because who needs to see or hear or chew? 

    So those are some BIG gaps.

    A lot of Medicare Advantage plans offer to fill those gaps:

    MA Ad 2: This card I’m holding in my hand, it’s an example of an all-in-one Medicare Advantage membership card.

    Dan: Lots of them include what’s missing  

    Woman in Ad2: That card helps me with my vision costs, my dental costs.

    Dan: Some of them even subsidize the premium you’d be paying to the feds, even bringing it down to zero. You can see how appealing that is.

    … and insurance companies hammer that appeal home with floods of TV ads

    Plus direct mail, phone calls, and facebook ads out the wazoo. None of which mention the downsides to Medicare Advantage… 

     which are basically: All the downsides we’re all familiar with from dealing with insurance companies. 

    Their network might not include your doctors and providers. It might not include very many providers near you at all. 

    And once you find an in-network provider, the insurance company can make you jump through hoops like pre-authorization. Or deny a claim. And then you get to fight through an appeals process. 

    I talked with a guy in Texas, Robert Wolpa. He’s got HIV, a pacemaker, other stuff. He said he felt like he was spending half his days on hold, waiting to talk with badly-paid, badly-trained people.

    Robert Wolpa: I’m 71. I just turned 71 in November and I’ve got, I’ve got a little of the HIV cognizant crap. Like, my short term memory is gone. And I think to myself, what have I gotten myself into?

    Dan: This is the thing: You can be 65 years old, in totally decent shape, playing pickleball or whatever, never seeing a doctor. 

    But when you pick Medicare Advantage, most of the time you’re also choosing for an older, sicker version of yourself. Who may need to see specialists, and who may not have as much capacity to fight with insurance companies. 

    I mean, most relatively young and healthy people have a hard enough time. 

    This is where Traditional Medicare starts to look much more appealing. Practically every provider takes it, and denials are almost unheard of.

    But for most people, if you’ve chosen Medicare Advantage, it’s a no-backsies situation. 

    You can still sign up for Traditional Medicare, but you may not be able to get a Medigap policy. 

    For one thing, it may not be in your budget. Robert Wolpa got a quote: Almost 500 bucks a month. Like a third of his social security check.

    Robert Wolpa: And I said, okay. Next option.

    Dan: And lots of people don’t have the option at all. In most states, if you don’t sign up at age 65, Medigap plans are allowed to reject you if you have… pre-existing conditions. 

    Sarah Jane Tribble: It’s sort of shocking, actually, right? Like, the Affordable Care Act passes and makes it so that everybody with pre existing conditions can get insurance no matter what, but it leaves out the people who might need that the most, who are 65 and older. 

    Dan: That’s the person who had introduced us to Robert Wolpa, and helped us understand this whole issue. Sarah Jane Tribble,a reporter with our pals at KFF Health News had just published her own story about the pitfalls of Medicare Advantage.

    This comes as a big surprise to a LOT of folks — as Sarah Jane found out while she was reporting her story, and talking about it with friends.

    With all of these… advantage — all the marketing, and all the gaps it fills– Medicare Advantage has grown by leaps and bounds in its 20-some years. 

    At this point, the majority of seniors are on Medicare Advantage.

    So, OK: Long recap, but. That’s what we KNEW a couple of years ago. 

    And it turns out — based on what happened last fall, and what’s about to happen this year — the problems are way worse than we knew. 

    Which brings us back to our friends in Minnesota. In early October 2025.

    News anchor 1: In 90 days, thousands of Minnesotans will lose their Medicare Advantage coverage.

    News anchor 2: Many major health care providers are dropping their Medicare Advantage plans in 2026. 

    Dan: So, Emily. What the heck happened?

    Emily: So that local nonprofit insurance company – UCare– they went broke, and all their Medicare Advantage plans got pulled from the market. Pretty quickly after that, UnitedHealthcare, Aetna, and others sent break up letters of their own to thousands of their beneficiaries.

    Lots of people turned to insurance brokers for help. 

    But many brokers weren’t calling them back. Because things had started going haywire for them too. Insurance broker Alison Ebert told us she was used to getting paid in cookies and coffee – and this time around, she would mean that literally — because in the days leading up to open enrollment she got an unusual call from her contact at UnitedHealthcare.

    Alison Ebert: She said, “I just wanna let you know before you get the email, we’re not paying commissions this year.”

    Emily No commissions. No payment from the insurance company for anyone she would enroll in their Medicare Advantage plans. Which is for health insurance brokers — the whole business model. 

    Alison Ebert: And my heart just sunk. That was the first phone call, and one by one thereafter, all the major carriers except for Allina Health Aetna, followed suit.

    Emily: Other brokers in Minnesota told me the same thing. I asked Alison: why do you think they cut commissions? She says a rep for one of the big companies told her the ugly truth. 

    Alison Ebert: With UCare exiting the market,” she said, “Let’s face it, we don’t want everybody that sunk UCare on our plan. And so this is how we’re gonna c- curb enrollments.” 

    Emily:  Alison got the message: These insurance companies wanted to curb enrollments. They specifically didn’t want to insure people who they tho  ught “sunk UCare” — meaning, people who used health care. Who filed claims. Who cost money.If brokers didn’t get commissions for selling plans to these folks, a lot fewer of them would sign up.  

    Alison Ebert: Because they’ve always told us about 80% of the sales comes through brokers like us.

    Emily: Now, a few weeks later, it was October 15, open enrollment was starting, and her phone was ringing off the hook. 47 people on day one. And more every day after that. Plus all her regular clients — the ones whose grandkids she knew by name.

     Alison had to decide what to do  — could she afford to help all those people for free? 

    Alison Ebert: I have kids. I mean, I deserve to get paid. I need to put gas in my tank to go to these people’s homes.  

    Emily: But Alison didn’t think it was right to leave people hanging.

    Alison Ebert: I left a message on my answering machine saying, “You know, due to the fact that we’re not getting paid this season, a lot of brokers left the market and I’m just returning calls as they come. But just be aware that it might take me a couple weeks to get back to you.”

    Emily: Instead of going to everyone’s house, she set up office hours at a coffee shop to be able to see as many people as possible.

    Meanwhile… Kelli Jo Greiner and her colleagues at the state’s Medicare hotline were scrambling too.

    Kelli Jo Greiner: We had wait times of two hours. Nobody wants to wait for even 10 minutes, let alone two hours

    Emily: She and her team had to improvise.

    Kelli Jo Greiner: We have staff that don’t usually do Medicare counseling. They help with, like, long-term care and other areas, and we even put those folks on the phones to help

    Emily: And she wrangled a weekly spot on FOX 9 in the Twin Cities to answer big questions.

    Amy Hockert: Medicare Monday is what we’re calling it. A lot of changes coming in 2026. Kelli Jo, thanks for joining us.

    Kelli Jo Greiner: Well, thank you. I’m glad to be here again. 

    Amy Hockert: All right. Well, let’s roll through it here.

    Emily: Kelli Jo told viewers: The most important thing is to be proactive. If you don’t do anything, the system will put you into traditional Medicare — but without a Medigap plan. Oh, and by the way, she told them: Your drug plan will probably disappear too, unless you sign up for a new one.

    So — she said, the good news, as far as it goes is: Right now you have a choice. And it’s just like the one you had when you were 65. You get to basically start over if you want, and get a Medigap plan even if you have a pre-existing condition. This is a special situation, they can’t reject you. 

    And once you’re on they can’t tell you which doctors to see. Almost every doctor in the country takes traditional Medicare.   

    Kelli Jo Greiner: And for many people that is a huge advantage,’cause we have a lot of snowbirds here that go south for the winter.

    Emily: But she says most people she talked with decided they just couldn’t afford those Medigap premiums. They were stuck with Medicare Advantage. Only now they had fewer and crummier Medicare Advantage plans to choose from. 

    Also, they were more expensive than these folks were used to. 

    Kelli Jo says a lot of people had been on plans with no monthly premium — but now all those plans were gone.  

    Kelli Jo Greiner: and so they ended up having to switch to a plan with a premium

    Emily: And in a lot of cases, without some extra benefits that Kelli Jo says are a big draw. Like discounts on groceries — or free gym memberships, a feature called Silver Sneakers.

    Kelli Jo Greiner: and I cannot even tell you how many people called us about Silver Sneakers. They were so upset about that change.

    Emily: So people ended up paying more than they were used to —  and getting less. 

    Dan: OK. So to recap: some Medicare Advantage plans disappeared.

    Emily: Yes.

    Dan: The remaining plans weren’t great.

    Emily: Right.

    Dan: And most people chose them anyway, because they couldn’t afford Medigap.

    Emily: Correct. And we can expect more of the same this year– and for who knows how many years ahead.

    Dan: So Medicare Advantage is getting shakier– even while it keeps growing. 

    Coming right up: how the dynamics behind all of this add up to trouble for all of Medicare. And what we can maybe do about it.   .

    This season of An Arm and a Leg is a co-production of Public Road Productions and KFF Health News — that’s a non-profit newsroom covering health issues in America. Their reporters are amazing — you’re about to hear from another of them. We’re honored to be their colleagues.

    Dan: Kelli Jo Greiner told us many folks who lost their Medicare Advantage plans  just couldn’t afford Medigap supplements. 

    Which, as we’ve been learning, has been one of the big dynamics behind the growth of Medicare Advantage in the first place. 

    Emily: Our colleague Julie Appleby found recently, that dynamic is getting starker.

    Julie’s a senior correspondent with our pals at KFF Health News.  

    Julie Appleby: I cover all things health insurance pretty much, uh, from the Affordable Care Act to Medicare, other kinds of health insurance programs, uh, that kind of thing. 

    Emily: Earlier this year, Julie got a call from a broker in Illinois.

    Julie Appleby: And he was telling me that more than, like, 80 of his customers were enrolled in a Medicare supplement,

    Emily: A specific plan. One that usually had low premiums. 

    Julie Appleby: But they suddenly raised their rates by 45%. And he said, “In my 49 years of doing business as a broker, I’ve never seen a premium increase be effective immediately on everyone. So I thought, “Hey, I’m gonna start looking into this.”

    Emily:  She found some good data from a company called Telos Actuarial — which showed: this price hike was part of a trend.

    Julie Appleby: There were increases going on kind of throughout the industry.

    Emily:. On average, the data showed premiums on Medigap went up almost 17% from the previous year.

    Not as high as that one plan with 45 percent increase, but still nothing to sneeze at. Brokers and other experts told her: That kind of increase used to be almost unheard of. But for the last bunch of years, it’s become a new normal. 

    Julie sees a connection with the growth of Medicare Advantage. 

    To understand it — and why everything about Medicare could be getting shakier and shakier — Julie’s gonna introduce us to a key term: Risk Pool. It’s a big part of how insurance prices get set.

    Julie Appleby: Insurance is a giant pool, right? We all are in the pool, and everybody kinda shares the cost. The insurance company has to sit down and try to figure out, “Well, gee, I’ve got this pool of people. How sick are they? How, how often are they gonna go to the doctor? How often are they gonna be hospitalized?” And then calculate out, “Okay, so what might that cost me?”

    Emily: So a lot depends on: Who’s in the risk pool for any given plan? If Medigap plans are more expensive than Medicare Advantage — but provide better coverage — then, who’s gonna choose the Medigap? People who think they’re gonna *need* that better coverage. Sicker people.

    And with millions of people getting the chance at do-overs — because their Medicare Advantage plans got nuked — these Medigap insurers have a bunch of new customers, who — it seems reasonable to think — may be sicker.  

    Julie Appleby: So these carriers are, then having to think, “Wow, I’m taking all these people on in this region, so I’m gonna have to raise my premiums to cover what might be those expected costs.” 

    Emily : And as premiums grow and grow, what we could see is a kind of vicious cycle. Because as new people turn 65, they’re looking at Medigap premiums that are harder and harder to afford.

    So more and more people are attracted to Medicare Advantage. I spoke with a researcher named Laura Skopec – she studies Medicare at the Urban Institute, an economic and social policy think tank. Here’s how she put it: If this trend continues — with Medigap prices driving more people to Medicare Advantage

    Laura Skopec: We’re gonna see a traditional Medicare that is sicker and wealthier, which is sort of a weird combination, but it’s gonna be sort of the sickest people that really need good access to specialists, wanna be able to go to the cancer center, you know, any sort of doctor they wanna go to, and the people that can afford Medigap

    Emily: Like, the sicker you are, the more you need this, and the more people who need it, the more expensive the supplements will be.

    Laura Skopec: The risk pool just keeps on worsening.

    Emily: So, expect Medicare Advantage to keep growing. And — as Laura points out — getting more expensive.

    Laura Skopec: The Medicare Payment Advisory Commission says we spend about fourteen percent more for everyone who chooses Medicare Advantage over traditional Medicare, and that was really not the point of the Medicare Advantage program, right? It was supposed to use sort of private sector processes to lower costs in Medicare, and it has not done that. 

    Emily: In fact, insurance companies are under increasing scrutiny for overcharging the government for Medicare Advantage. 

    The feds have been trying to impose some rules to cut down on those extra profits – all very technical stuff which we could devote a whole episode to.     

    Dan: Maybe we should

    Emily: Yeah and crackdown may have played a role in insurance companies pulling some of these plans off the market. And they say they’re gonna keep yanking more plans off the market unless they get MORE federal dollars. 

    Laura: They’re saying that their costs are going up for paying claims, which is probably true, and they point to market exits and other issues as, like, we need a pay bump here to stay in the market.

    Emily: All of this — pulling plans off the market, reducing benefits, trying to control who enrolls in their plans — all of this stuff is likely to keep happening. 

    So we should talk about what that looks like on the ground, and how seniors can navigate all these changes. 

    Remember Erin in Cambridge, Minnesota? 

    What happened to her really exemplifies how this kind of thing can play out. And how we can support each other.

    So Erin had gotten kicked off her plan when the whole enterprise behind it, UCare, collapsed.

    Erin had been really happy with UCare for the four years she was on one of their Advantage plans.

    Erin: You call their customer service and they are very helpful. I loved it.

    Emily:  she had access to specialists. 

    Erin: A thoracic, a neurologist, a urologist, a nephrology. An ENT specialist. 

    Emily: Erin had suffered four heart attacks in her late fifties. Because she couldn’t work, she started getting social security and Medicare early — when she was 58. She doesn’t really remember how she ended up picking Medicare Advantage over traditional Medicare.

    But it was working for her. Until they pulled the rug out from underneath her.

    Erin: I did not want them to go anywhere. I heard that, I was just in tears.

    I was so mad. I was like, “No. Now what do I do?” And I look at my husband and said, “Now what?” “

    Emily: And she says her husband had the answer immediately.

    Erin:Well, we’ll just call Desi.”

    Emily: We’ll just call Desi.

    Dan: Wait a minute–  Who is Desi?

    Emily: You gotta meet Desi. 

    Desi Panek: I’m Desi Panek, and I work at the Seven County Senior Federation here in Mora, Minnesota.

    Emily: That’s a member-led organization of seniors in eastern and central Minnesota who came together to advocate for themselves, and to help each other with transportation and other stuff seniors need. Including: signing up for — and dealing with — Medicare. 

    I met Desi and her boss Lisa Krahn, the Federation’s director, as they were gearing up for this year’s annual enrollment period. 

    Lisa: It can’t be as bad as it was last year 

    Emily: Yeah yeah. 

    Desi: We’ll find out soon. 

    Lisa: Oh, God 

    Emily: Yep, hold onto your hat. 

    Emily: Yep, they’re still dealing with the fallout from last year. This is Lisa:

    Lisa Krahn: Still quite a few people who show up, who are calling now, who don’t realize that they haven’t had a plan all year saying, “I just don’t have anything because my old plan left. Well, I wasn’t really paying attention to the mail they were sending me,” kind of a thing.

    Emily: Some of those people only found out when they got a bill in the mail. Or when they tried to pick up a prescription, and had to pay out of pocket cuz they didn’t have a drug plan anymore. 

    Luckily, Erin got the news before it was too late. She and her husband called Desi, and Desi helped them enroll in a new Medicare Advantage plan. Which Erin says, isn’t as good. 

    Erin: Right now I’ve got $1,700 out of pocket going to a pair of hearing aids

    Emily: She’s not a fan of the customer service. And she says she had to stop taking one of her preventative medications because her drug plan changed.

    Desi and Lisa are operating very much at ground level helping people like Erin, but they definitely have thoughts about the big picture –especially the stark choice between Medicare Advantage and traditional Medicare.

    Lisa Krahn: original Medicare is that thing you’ve been waiting your whole life to get. It’s good everywhere. And once you’re in, you’re in. 

    Emily: But it’s become too expensive for most people. Meanwhile, Medicare Advantage can really limit people’s access to care.

    Lisa Krahn: So, looking for a middle ground between those, it’s, it’s… There, there should be better choices, frankly, instead of such extreme ones.

    Desi Panek: Extreme is a really good word for that. I agree. 

    Emily: Extreme meaning there’s a big hole in one and there’s too many…

    Lisa Krahn: Restrictions on the other. But all the millions we’re dumping into advertising and these private companies, that could have filled the holes on original Medicare a long time ago. And that’s just antithetical to the function and the existence of the insurance industry, which, like the monarchy, maybe we can stop believing in. I’m revealing myself as a single-payer Medicare for All advocate, but we need better Medicare, frankly, you know? It always been shortchanged.

    Emily: Dan, speaking of Medicare For All.

    Dan: Yeah we really shouldn’t do an episode like this without mentioning it. Especially because it’s been coming up so much in this year’s election season. In Michigan, Abdul El-Sayed won the Democratic Senate primary, and Medicare for All was his number-one pitch.

    Abdul El Sayed: Yes, we really can guarantee healthcare in this country. Yes, we really can do it while spending a lot less and getting a lot more if our healthcare doesn’t still fund tens of millions of dollars in healthcare CEO, uh, salaries on top of it.

    Emily: People like Lisa — and Abdul El-Sayed — think of Medicare for All as a way to also plug the holes in existing Medicare. 

    Dan: Well, huh. OK, I mean, one thing I’m really tuning into is that all these big gaps in Medicare are all driven by the fact that ALL of Medicare — our big public benefit — is actually set up so it requires insurance companies to make a profit in order for it to function. Whether they’re selling Medicare Advantage plans, or Medigap policies.

    But then, how do Medicare for All advocates say that spreading Medicare to everybody makes the math actually work better?

    Emily: It’s all about that term Julie Appleby introduced us to:  Risk pool. How “risky” the people you’re insuring — the pool — are as a whole. Meaning, how much health care they need on average. The calculations change a lot when the pool is everyone, including people who are 25 as well as 65 and 95 — and when tax money funds health care directly instead of filtering it through private health insurance companies to administer and also take a profit.

    In fact, a recent study out of Yale estimates that Medicare For All — that is a Medicare that is completely void of private insurance companies — would reduce annual health expenditures by 1 trillion dollars every year.

    Dan: But that’s not just taking insurance companies out of Medicare — it’s taking them out of the whole U.S. health care system.

    Emily: Right. In the meantime, some politicians in Washington are talking about tweaks — big and small — to just Medicare itself. 

    Vermont Senator Bernie Sanders–

    Dan: the original Mr. Medicare For All 

    Emily: Yeah – in the meantime, he says we should extend traditional Medicare to cover vision, hearing, and dental. He’s introduced a bill in the Senate to do just that. 

    And Oregon Senator Ron Wyden recently introduced a bill that would put an out-of-pocket max on traditional Medicare. That way, people wouldn’t need supplements as much, and Medicare Advantage wouldn’t look as tempting.

    Both of those ideas would mean putting more federal money toward traditional Medicare.

    Dan: Which doesn’t SEEM like something Congress is likely to do. But what this whole story shows is: it seems like it’s gonna cost us either way. Either we put more public dollars into traditional Medicare, or we keep paying higher prices, collectively and individually,

    As for the here and now. If you have Medicare Advantage, but you don’t have a Desi or a Lisa to call, Emily, they gave you a breakdown of what you need to know.

    Emily:Yep. Their first piece of advice: open every piece of mail from your insurance company. That’s where you’re going to find out whether your plan is being cancelled. Or where you might find out they’re trying to auto-enroll you into a new plan, which might not be the best one for you.

    Desi Panek: The past couple of years we’ve had plans that end a specific plan, but will auto-enroll the e- the enrollee into another plan in the same company.

    Lisa Krahn: Crosswalking

    Desi Panek: Yes, so that’s a big deal. Pay attention to your mail. Um, you’re gonna get stuck with huge premiums if you just let it roll.

    Emily: And find someone to talk to.

    Remember Kelli Jo who runs the Medicare hotline for Minnesota? Every single state has one of those agencies. They’re called SHIP — S H I P — state health insurance assistance program. Google your state, SHIP, and Medicare

    If you can’t get through, there’s always insurance brokers. Desi has some advice on measuring up whether a broker is trustworthy.

    Desi Panek: Ask them if they sell every product available to you in your area. That’s one of the biggest things. I think that a lot of people just assume they’re gonna go to a broker or an agent and they’re gonna get the full scope, and that’s not necessarily true.

    Emily: You might want someone who sells Medigap supplements as well as Advantage plans. Someone who does that may be less inclined to push you into whatever’s paying them the highest commissions.

    Desi Panek: Word of mouth is a big deal for a lot of people, so asking your friends, your neighbors, uh, “Who did you work with? Are you happy? Are you unhappy? What was the experience like?”

    Dan: Talking to your friends and neighbors. It’s like, we gotta rely on each other.

    Emily: Which is why I’m kind of obsessed with this Senior Federation thing. People banding together to share information and resources to navigate this ongoing mess.

    Desi and Lisa’s group has been operating since 1975. There used to be a robust network of similar groups across the state. Theirs is the last one, but Desi says they’re going strong.

    Desi Panek: We’ve got our beautiful community and our thrift stores that keep our doors open and allow us to give that good information out, um, whether it’s what people wanna hear or not.

    Dan: And it went by kinda fast but I think I heard her say thrift stores?

    Emily: Yep! They have a side hustle. 

    Lisa Krahn: We run two thrift stores, the One More Time stores, which give us financial independence. So we’re not dependent on just memberships and just counseling fees or service fees. 

    Emily: That’s awesome, yeah, I’m dying to go to those thrift stores. I saw it on the website and I was like…

    Desi Panek: Did you see that we won Minnesota’s best thrift store?

    Emily: Stop it.

    Desi Panek: I mean it.  

    Emily: That’s so cool. Oh my God. 

    Lisa Krahn: By the Minnesota Star Tribune, yes. It was a popularity contest.

    Emily: Amazing. Wow.

    Dan: Wow for sure. Emily, thank you so much for all of this reporting.

    So here’s where we landed: Medicare is way more broken than we knew!  And we already knew it was kind of a confusing mess with a lot of holes. 

    Fixing it will require a huge lift.  The kind of thing that hasn’t seemed like a political possibility. And everybody will have BIG differences of opinion about how a fix should work. There are people who think the government shouldn’t be involved in health care at all. 

    Meanwhile, we’ve got what we’ve got.  We’ve got each other. 

    And… you just never know what might be possible.

    Next time on An Arm and a Leg, we’ll hear about what might be the most radical health care experiment since Medicare itself. 

    And the two guys — a Democrat and a Republican — who made it happen.

    Till then, take care of yourself. 

    This episode of An Arm and a Leg was produced by Emily Pisacreta, with help from our summer intern Lynn Barbera and me, Dan Weissmann— and edited by Ellen Weiss. Izabella Kulkarni provided additional production help.

    Reporting for this story was supported in part by Arnold Ventures. Listeners like you are our biggest source of support, and we need you more than ever. If you like what you’re hearing and want it to continue, head to arm and a leg show dot com, slash, support.  

    Adam Raymonda is our audio wizard.

    Our music is by Dave Weiner and Blue Dot Sessions. 

    Amanda Boyd is our Operations Manager. Bea Bosco is our consulting director of operations. 

    An Arm and a Leg is produced in partnership with KFF Health News. That’s a national newsroom producing in-depth journalism about health issues in America and a core program at KFF, an independent source of health policy research, polling, and journalism.

    Zach Dyer is senior audio producer at KFF Health News. He’s editorial liaison to this show.

    An Arm and a Leg is distributed by KUOW, Seattle’s NPR news station.

    And thanks to the Institute for Nonprofit News for serving as our fiscal sponsor.

    They allow us to accept tax-exempt donations. You can learn more about INN at INN.org.

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    You can join in any time at arm and a leg show, dot com, slash: support.

    Thanks! And thanks for listening

  • STAT+: The last ‘breakthrough’ devices to get special treatment from Medicare

    STAT+: The last ‘breakthrough’ devices to get special treatment from Medicare

    Katie covers the impact of health technology on patients, clinicians, and businesses. Her stories explore the price tag of clinical AI, digital health at the FDA, and the boom in direct-to-consumer telehealth. Confidential tips can be sent on Signal at palmer.01.

    In the last month, manufacturers have announced “breakthrough” status from the Food and Drug Administration for a menagerie of devices: triage algorithms for abdominal CT scans, diagnostic panels for urinary tract infections, and thrombectomy robots, to name a few.

    They’re coming in just under the wire: As of October, new breakthrough-designated devices will no longer be eligible for special treatment when it comes to qualifying for extra Medicare payments. These devices, and more than a dozen others, are included in the latest update of STAT’s Breakthrough Device Tracker, which since 2022 has captured nearly 800 devices reported to have FDA breakthrough status. 

    In August, the Centers for Medicare and Medicaid Services finalized the removal of pathways that have made it easier for breakthrough devices to qualify for supplementary Medicare payments for both inpatient and outpatient use. Since 2020, devices that received the designation from the FDA have been able to qualify for new technology add-on payments and transitional pass-through payments without proving they provide a substantial clinical improvement over alternatives, or that they are new. 

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