Latest news with #JonathanGruber
Miami Herald
23-06-2025
- Business
- Miami Herald
Trump Administration Says Health Insurance Move Will Save $12 Billion
The Centers for Medicare & Medicaid Services (CMS) has announced it is in the final stages of implementing a new rule that it says will 'lower individual health insurance premiums' by 5 percent on average. CMS said the move is expected to save American taxpayers up to $12 billion in 2026, by 'combating the surge of improper enrollments in the Affordable Care Act (ACA) Exchanges.' Concern has been raised by some that these new measures will push many Americans off their health coverage. 'They will indeed save government money, but only by throwing off the ACA rolls millions of individuals who deserve to be on,' Jonathan Gruber, a professor of economics at Massachusetts Institute of Technology, told Newsweek. Newsweek has contacted CMS via email for comment. According to a CMS release, the new rules are being brought in to tackle 'waste, fraud and abuse' in health insurance markets-an issue that is at the forefront of the Trump administration's policies. A Government Accountability Office (GAO) report from 2024 found that $100 billion was discovered in 'improper payments' in 2023 across the Medicare and Medicaid programs. While wasteful spending in health insurance markets has been targeted by the administration to lower the tax burden for Americans, critics are concerned that sweeping cuts and changes will only push many off health coverage, subsequently driving up costs in the long-term. The new regulation, known as the 2025 Marketplace Integrity and Affordability Final Rule, will target 'improper enrollments' in the Affordable Care Act (ACA) Exchanges via a number of measures. It would repeal the monthly special enrollment period (SEP) for individuals with household incomes at or below 150 percent of the federal poverty level, which CMS called was a kind of loophole for unauthorized enrollments. The policy has been 'used by some agents and brokers to improperly enroll ineligible consumers and perform unauthorized plan switching to gain commissions,' CMS said. Income verification will now be required for most new and auto-renewed enrollments receiving premium subsidies to 'ensure people qualify for the premium subsidies they receive,' CMS added. There will also be additional eligibility requirements for the majority of enrollments through SEPs, in order to close 'loopholes that allowed people to wait to enroll until they needed care,' CMS said. In addition, the rule will reduce advanced payments of the premium tax credit (APTC) by $5 a month for auto-renewed plans without eligibility verification. Most of these policy changes are temporary and will expire after the 2026 plan year-they are simply being used as measures to 'immediately tamp down on improper enrollments and the improper flow of federal funds,' according to CMS. Experts have warned about the impact these measures could have on Americans, with Timothy S. Jost, a professor of law at Washington and Lee University telling Newsweek, 'as many as 1.8 million people could lose ACA coverage.' 'This is an addition to the 4.2 million who will lose coverage because the Congress is not extending the enhanced premium tax credits that were adopted during the Biden administration,' he added. Additional actions being made by CMS in regard to ACA Exchanges include a move to ensure federal ACA subsidies will no longer be available 'to help cover the cost of specified sex-trait modification procedures to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex.' Jonathan Gruber, a professor of economics at Massachusetts Institute of Technology, told Newsweek: 'This is classic doublespeak. These actions will throw millions of people off the ACA rolls by setting up arbitrary administrative barriers that make it hard to enroll.' He added: 'There is undoubtably fraud in ACA exchange enrollment. But this is a blunt solution that will remove many deserving enrollees for every undeserving enrollee and lead to hardship for millions.' Timothy S. Jost, a professor of law at Washington and Lee University, told Newsweek: 'The rules that have just been published will dramatically reduce enrollment in the health insurance exchanges by creating barriers to enrollment leaving many people uninsured. The rules are likely to increase premiums rather than reduce them because the added bureaucratic barriers to enrollment will discourage healthy individuals from enrolling and those covered will be much sicker and more costly. To the extent that rules do reduce premiums for some, it will be primarily because the policies they will be buying will be of lower value, with higher deductibles and co-payments and because the premium tax credits they receive will be reduced.' He added: 'The rule may reduce government expenditures, but simply because it reduces the number of Americans covered and the value of their coverage. There has been some fraud by brokers in the federal marketplace but this was already being addressed by excluding fraudulent brokers.' Robert F. Kennedy Jr., U.S. Health and Human Services Secretary, said: 'We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse. With this rule, we're lowering marketplace premiums, expanding coverage for families, and ensuring that illegal aliens do not receive taxpayer-funded health insurance.' Dr. Mehmet Oz, CMS Administrator, said: 'CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it. This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline.' The finalized policies will apply to plan years 2025 and 2026, after which they are set to expire. Related Articles Aflac Cyber Breach May Expose Customer Health Data, Social Security NumbersMedicare Update: Lawmakers Introduce Bill to Expand Health Care ProgramNew Yorkers Warned of 38 Percent Spike in Health InsuranceMap Shows States Where People Are Being Removed From Health Care Plan 2025 NEWSWEEK DIGITAL LLC.
Newsweek
23-06-2025
- Health
- Newsweek
Trump Administration Says Health Insurance Move Will Save $12 Billion
Based on facts, either observed and verified firsthand by the reporter, or reported and verified from knowledgeable sources. Newsweek AI is in beta. Translations may contain inaccuracies—please refer to the original content. The Centers for Medicare & Medicaid Services (CMS) has announced it is in the final stages of implementing a new rule that it says will "lower individual health insurance premiums" by 5 percent on average. CMS said the move is expected to save American taxpayers up to $12 billion in 2026, by "combating the surge of improper enrollments in the Affordable Care Act (ACA) Exchanges." Concern has been raised by some that these new measures will push many Americans off their health coverage. "They will indeed save government money, but only by throwing off the ACA rolls millions of individuals who deserve to be on," Jonathan Gruber, a professor of economics at Massachusetts Institute of Technology, told Newsweek. Newsweek has contacted CMS via email for comment. Why It Matters According to a CMS release, the new rules are being brought in to tackle "waste, fraud and abuse" in health insurance markets—an issue that is at the forefront of the Trump administration's policies. A Government Accountability Office (GAO) report from 2024 found that $100 billion was discovered in "improper payments" in 2023 across the Medicare and Medicaid programs. While wasteful spending in health insurance markets has been targeted by the administration to lower the tax burden for Americans, critics are concerned that sweeping cuts and changes will only push many off health coverage, subsequently driving up costs in the long-term. File photo: a Department of Health and Human Services form proposed for use to apply for low-cost insurance from Medicaid or the Children's Health Insurance Program. File photo: a Department of Health and Human Services form proposed for use to apply for low-cost insurance from Medicaid or the Children's Health Insurance Program. J. David Ake/AP What To Know The new regulation, known as the 2025 Marketplace Integrity and Affordability Final Rule, will target "improper enrollments" in the Affordable Care Act (ACA) Exchanges via a number of measures. It would repeal the monthly special enrollment period (SEP) for individuals with household incomes at or below 150 percent of the federal poverty level, which CMS called was a kind of loophole for unauthorized enrollments. The policy has been "used by some agents and brokers to improperly enroll ineligible consumers and perform unauthorized plan switching to gain commissions," CMS said. Income verification will now be required for most new and auto-renewed enrollments receiving premium subsidies to "ensure people qualify for the premium subsidies they receive," CMS added. There will also be additional eligibility requirements for the majority of enrollments through SEPs, in order to close "loopholes that allowed people to wait to enroll until they needed care," CMS said. In addition, the rule will reduce advanced payments of the premium tax credit (APTC) by $5 a month for auto-renewed plans without eligibility verification. Most of these policy changes are temporary and will expire after the 2026 plan year—they are simply being used as measures to "immediately tamp down on improper enrollments and the improper flow of federal funds," according to CMS. Experts have warned about the impact these measures could have on Americans, with Timothy S. Jost, a professor of law at Washington and Lee University telling Newsweek, "as many as 1.8 million people could lose ACA coverage." "This is an addition to the 4.2 million who will lose coverage because the Congress is not extending the enhanced premium tax credits that were adopted during the Biden administration," he added. Additional actions being made by CMS in regard to ACA Exchanges include a move to ensure federal ACA subsidies will no longer be available "to help cover the cost of specified sex-trait modification procedures to align an individual's physical appearance or body with an asserted identity that differs from the individual's sex." What People Are Saying Jonathan Gruber, a professor of economics at Massachusetts Institute of Technology, told Newsweek: "This is classic doublespeak. These actions will throw millions of people off the ACA rolls by setting up arbitrary administrative barriers that make it hard to enroll." He added: "There is undoubtably fraud in ACA exchange enrollment. But this is a blunt solution that will remove many deserving enrollees for every undeserving enrollee and lead to hardship for millions." Timothy S. Jost, a professor of law at Washington and Lee University, told Newsweek: "The rules that have just been published will dramatically reduce enrollment in the health insurance exchanges by creating barriers to enrollment leaving many people uninsured. The rules are likely to increase premiums rather than reduce them because the added bureaucratic barriers to enrollment will discourage healthy individuals from enrolling and those covered will be much sicker and more costly. To the extent that rules do reduce premiums for some, it will be primarily because the policies they will be buying will be of lower value, with higher deductibles and co-payments and because the premium tax credits they receive will be reduced." He added: "The rule may reduce government expenditures, but simply because it reduces the number of Americans covered and the value of their coverage. There has been some fraud by brokers in the federal marketplace but this was already being addressed by excluding fraudulent brokers." Robert F. Kennedy Jr., U.S. Health and Human Services Secretary, said: "We are strengthening health insurance markets for American families and protecting taxpayer dollars from waste, fraud, and abuse. With this rule, we're lowering marketplace premiums, expanding coverage for families, and ensuring that illegal aliens do not receive taxpayer-funded health insurance." Dr. Mehmet Oz, CMS Administrator, said: "CMS is restoring integrity to ACA Exchanges by cracking down on fraud, protecting American taxpayer dollars, and ensuring coverage is there for those who truly need it. This is about putting patients first, stopping exploitation of the system, and realigning the program with the values of personal responsibility and fiscal discipline." What Happens Next The finalized policies will apply to plan years 2025 and 2026, after which they are set to expire.
Boston Globe
20-05-2025
- Health
- Boston Globe
Congress' budget aims to target Medicaid fraud. In Massachusetts, the reality is more complicated.
Locally, the cost of MassHealth, the state's Medicaid administrator, grew almost 50 percent in inflation adjusted dollars from 2014 to 2023, according to the 'The growth that we've seen, that line item year over year, that has to flatten,' said State Representative Marc Lombardo, a Billerica Republican. Related : Advertisement The proposal passed Sunday by the House Budget Committee would make it more difficult for people to apply for Medicaid, such as by requiring some beneficiaries to be employed and requiring the state to more frequently confirm MassHealth members' eligibility. The proposal could cut the national deficit by $625 billion over 10 years, according to a by 2034, according to the CBO. Advertisement It's a myth that there are hordes of people fraudulently receiving Medicaid benefits, experts said. 'These are right-wing rhetorical covers for kicking people off Medicaid,' said Jonathan Gruber, an MIT economics professor who specializes in health care. Many of those who could end up uninsured are people who are eligible for Medicaid but would struggle to overcome barriers, such as additional paperwork and record keeping, which the Congressional proposal would likely create, he said. MassHealth officials offered a 'high estimate' that the budget proposal could make Medicaid inaccessible to hundreds of thousands and could cost the state $1 billion. More people participate in MassHealth than they did a decade ago, but the increasing cost of the program is also attributable to the increasing cost of health care and because MassHealth recipients tend to have more serious health needs. At the heart of Congressional Republicans' budget priorities are trillions in The Centers for Medicaid & Medicare Services reported about 5 percent of Medicaid payments nationally, about $31 billion, were About three-fourths of those improper payments are attributable to paperwork or record-keeping errors, not intentional fraud, said Timothy Hill, senior vice president for Health at the American Institutes for Research, a nonprofit that works with providers to improve health care delivery, in a recent discussion about Medicaid fraud and abuse hosted by the health policy analysis organization KFF. 'It doesn't mean a service wasn't provided, it doesn't mean somebody didn't get care,' Hill said. 'What it does mean is that the rules that the agency established for getting payment weren't followed. All those errors could be corrected.' Advertisement When it comes to spotting true fraud, Massachusetts has a complex, overlapping screening process that involves the Office of the State Auditor, the Office of the Inspector General, the Attorney General's Office, the federal government, and MassHealth itself. They run algorithms that spot questionable billing patterns and assign state investigators to pore over records and interview MassHealth recipients, doctors, and care providers. What they find accounts for far less than one percent of the state's $20 billion MassHealth budget. Gina Cash, a lawyer who runs the state auditor's Bureau of Special Investigations, described the process her team uses to investigate fraud. Their focus is usually on individuals improperly receiving benefits, and the work starts with hundreds of tips, reports of people whose spending habits have raised questions about whether they are eligible for the MassHealth benefits they receive. About half of those warrant investigations, including scrutiny of people's circumstances and medical conditions. Her office identified close to Cash received public assistance to help pay for child care when she was a young mother just out of law school and has empathy for those who need such services. Related : 'The solution is not to cut, it's to continue to make oversight reforms,' she said. Experts noted fraudulent billing from providers, not individuals seeking benefits dishonestly, accounts for the vast majority of Medicaid fraud. Such cases can be prosecuted by the state Attorney General's Office Medicaid fraud unit. One recent case includes indictments against a Advertisement Massachusetts reported 13 Medicaid fraud convictions and 21 settlements in fiscal year 2024, according to the U.S. Department of Health and Human Services The state Office of the Inspector General focuses on specific aspects of the health insurance system, primarily looking for improper practices from providers. In a review of MassHealth services for children with autism from 2022 and 2023, the inspector general identified more than $17 million in 'We put a decent web together with the oversight agencies in the Commonwealth,' said Jeff Shapiro, the state's inspector general. Health policy experts noted that fraud has a specific definition: intentional deception to obtain an undeserved benefit. Waste and abuse are more subjective. Waste can involve a provider taking advantage of billing rules, but it's harder to identify. What may look like a glut of unneeded tests, for example, could turn out to be warranted after a deeper investigation into a person's medical needs. What qualifies as abuse can also be a matter of policy preferences. Almost all states use revenue from taxes on health care providers to support Medicaid expenses, and in the process boost their federal reimbursements. Some federal legislators say it's a way to Advertisement Massachusetts is expected to raise $2.3 billion through these taxes in fiscal year 2025, according to the Gruber, the MIT economist, said he generally doesn't like loopholes, but states wouldn't be able to afford coverage for poorer populations without taking advantage of this one. 'They are dramatically cutting the ability of states to take advantage to help Medicaid pay for underfunded programs,' he said. He is infuriated, he said, about the hypocrisy of public officials who are outraged by the idea of taxpayer money wasted through Medicaid. He contrasted the rhetoric around Medicaid fraud with the decision to cut staff at the 'Catching one or two rich tax cheats would raise so much more money than we can save with these provisions,' he said. Jason Laughlin can be reached at
Yahoo
05-04-2025
- Health
- Yahoo
Blue Cross Blue Shield and Southwestern Health Resources reach deal on new contract
After days of uncertainty, Blue Cross Blue Shield of Texas policyholders can breathe a sigh of relief knowing that the insurer has finally reached an agreement on a new contract with Southwestern Health Resources. The companies announced the deal in statements made late in the evening on Friday, April 4. 'Blue Cross and Blue Shield of Texas has agreed to terms with Southwestern Health Resources that protect our members' access to quality care offered by (Southwestern Health Resources) providers at fair prices,' Texas' largest health insurer said in a statement sent to the Star-Telegram. Blue Cross Blue Shield of Texas insures over 10.4 million people in the state. All members who lost access to more than two dozen major hospitals in the Metroplex on Tuesday once again have in-network access to Southwestern's medical facilities, and the coverage is retroactive, Blue Cross Blue Shield said. 'Any claims processed as out-of-network on or after April 1 will be reprocessed at the in-network benefit level,' a Blue Cross spokesperson said in the statement. The agreement will last for three years, according to a spokesperson for Southwestern Health Resources. 'This means all Texas Health and UT Southwestern hospitals, facilities and employed and affiliated providers are in network,' the spokesperson said. 'Patients can keep their scheduled appointment or schedule a new one and be assured that in-network rates will apply. We are honored to continue caring for (Blue Cross Blue Shield of Texas) members as an in-network provider.' The contract restores coverage to the following Blue Cross Blue Shield plans: ParPlan Blue Choice PPO Blue Essentials Medicaid Blue Cross Medicare Advantage PPO Blue Cross Medicare Advantage HMO Blue Advantage HMO and MyBlue Health Over a dozen Blue Cross Blue Shield policyholders reached out to the Star-Telegram this week to express frustration over interruptions to treatment. Several were dealing with recent diagnoses or ongoing treatment for life-threatening illnesses such as breast and thyroid cancer. 'This should not happen to people who get insurance, so they can stay healthy,' said Melanie Perry, who has monthly oncologist appointments as part of her treatment after surgery for breast cancer. 'The greed on both sides greatly affects people's lives — I feel very helpless and scared.' Speaking with the Star-Telegram on Wednesday about the fallout of the contract expiration, Jonathan Gruber, a healthcare economist at the Massachusetts Institute of Technology, said the situation serves as an example of why the government should regulate prices in the healthcare industry. 'If we regulated prices, there wouldn't be this problem,' Gruber said.
