Given all going on in healthcare, it is time to contemplate real reform.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses the fact that it is time to contemplate real reform given all going on in healthcare.

Key Takeaways:

Zeke Emmanuel, one of the key authors of the Affordable Care Act (ACA), had an interesting opinion piece in The Washington Post on December 2. It suggests many of the reforms I spelled out in my book, The Healthcare Labyrinth.

He calls out price as a huge concern for healthcare affordability and suggests site neutral payments and price caps.

There have been some promising developments this year, including a small step toward site neutrality and drug price reforms.

Price, costs, and premiums have been increasing dramatically (6% to 9%, if not more) annually, putting coverage out of reach.

That may mean we have to rethink comprehensive coverage. Some coverage may be better than no coverage at all or the inability to use your coverage.

There are some innovative ideas evolving that might encourage upfront primary care, including direct primary care tied to health savings accounts.

A new traditional Medicare pilot would also target controlling chronic conditions. It is a good idea.

Trump is now joining the crowds attacking health plans, arguing insurers make too much in profit. The last five years proves the declaration to be false.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

CMS issued some major regulatory proposals in its draft 2026 Medicare Advantage and Part D rule.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses the recently released draft 2026 Medicare Advantage (MA) and Part D rule. Some major regulatory changes are in store for plans.

Key Takeaways:

The proposed CMS MA and Part D rule for 2027 was issued timely despite the government shutdown. It includes some significant changes.

The Star changes were the biggest, including repeal of the Excellent Health Outcomes for All equity reward and the sunset of operational measures.

CMS' focus in the balance of the rule is reducing regulatory burden and streamlining regulations.

Various utilization management health equity requirements codified by the Biden administration are proposed for repeal.

Four RFIs were issued, including seeking input on reforming the risk adjustment and Stars programs due to perceived overpayments as well as poor quality outcomes.

As with the rule, new program audit guidance from CMS streamlines the audit process and follow-up.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

CMS wants a much tougher MA Star ratings program and that could challenge plans and mean billions in lost revenue.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses the fact that CMS wants a much tougher Star ratings program in Medicare Advantage and that could challenge plans and mean billions in lost revenue.

Key Takeaways:

Medicare Advantage Star ratings are in the doldrums. Little progress was seen in Star Year 2026 results.

Now, CMS says it wants to make the program even tougher. CMS is getting rid of "layup" measures -- mostly operational metrics – in favor of concentrating on more complex clinical measures to drive quality outcomes.

This is not a total surprise as the Biden administration telegraphed this before leaving. The change would shift emphasis to drug, health outcome, and improvement measures.

CMS also wants to eliminate the Excellent Health Outcomes for All reward slated to go into effect for SY 2027 because it dislikes anything health equity.

The proposal to eliminate the long-planned reward could be legally dubious.

Getting tougher and refocusing is not unreasonable, but it could mean billions in revenue is lost by MA plans. At least 25% of contracts could lose at least half a Star rating.

Complicating the Stars picture is MA plans' focus on dual eligibles and Special Needs Plans. These individuals tend to perform much worse on clinical measures.

To succeed, plans will need to invest more in Stars. The pivot to true healthcare outcome measures will require quicker and better data collection and analysis, better tracking and forecasting, ongoing strategy refinement, and novel tech-based interventions to close gaps on everyone.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

A new study looking at what UnitedHealthcare pays its sister providers could bring scrutiny of vertical integration in healthcare.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses a new study looking at what UnitedHealthcare pays its sister providers. This could bring scrutiny by CMS and Congress of vertical integration in healthcare.

Key Takeaways:

Vertical integration in healthcare is all the craze.

Large healthcare entities are especially plotting vertical integration strategies to grow.

Vertical integration leads to intercompany transactions among sister companies within the controlling entity.

These agreements occur between plans, PBMs, providers, service entities, and pharmacies.

Between 10% and 20% of Big Plan insurer spending is with sister companies.

These agreements are shown to have higher than arm's length or market reimbursement.

A recent study shows that UnitedHealthcare pays its sister company providers well more than other providers.

While vertical integration may not be a bad thing in some cases, insurers need to reform how they approach such agreements so as not to disadvantage consumers and businesses.

Congress and CMS, too, need to look at consolidation overall and these inside deals.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

The drug price reform arena is active, with a major announcement on drug rebate reform and GLP-1 weight-loss drug price reductions.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses the fact that drug price reform arena is active, with a major announcement on rebate reform and GLP-1 weight-loss drug price reductions.

Key Takeaways:

Cigna's Express Scripts PBM announced it will begin introducing net pricing and migrate in part away from drug rebates.

Consumers will get the benefit of the lowest price at drug counters. The new model will save members an average of 30% each month on brand drugs.

It will also enhance how it pays pharmacies.

Cigna says it will deploy the strategy for its plan offerings and offer the net price options as the default to all employer groups and clients.

It is a step forward but is not real reform – it does not eliminate rebates, is a hybrid approach, and many plans and employer groups may still maintain the rebate structure.

PBMs should not write the reform script, and the government should eliminate rebates entirely.

President Trump announced major concessions of GLP-1 weight-loss drugs for self-pay and Medicare, including a $50 co-pay cap.

There is much confusion surrounding when Medicare cost-sharing reductions go into force, whether those with obesity alone will truly benefit, and Medicare cost impacts.

The concessions do not impact Medicare drug price negotiations, and the president should ensure broad drug price reform across lines of business.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Donald Trump and the GOP may want another pass at repealing and replacing Obamacare. But they have never had a real plan.

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses that Donald Trump and the GOP may want another pass at repealing and replacing Obamacare. But they have never had a real plan.

Key Takeaways:

Just as midterm elections begin to kick into high gear, President Trump and other GOP officials are saying the want to take another pass at repealing and replacing the Affordable Care Act (ACA) or Obamacare.

CMS Administrator Dr. Mehmet Oz says the president has a hidden plan.

Trump himself urged the parties to get together to pass reform because Obamacare is so bad.

He then lambasted Democrats over the law in a social media post.

The GOP does not appear to have a plan to extend expiring the Exchange's enhanced premium subsidies to avert huge premium surges. The GOP is said to be talking about an extension with some conservative-minded reforms.

But we have never seen a true plan from the GOP that would not lead to a huge surge in the unsured rate – not in 2017, not during the 2024 election, not during the debate on the One Big Beautiful Bill, or now.

Americans deserve a measured subsidy extension with some reforms.

The GOP should put up a realistic plan for coverage or shut up about it. The periodic pronouncements are unsettling to the tens of millions of Americans who rely on the ACA for coverage.

Ripping apart the ACA as we know it now with nothing truly comprehensive to replace it with would mean millions losing coverage.

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance

Quiet Discussions On Capitol Hill On An Enhanced Subsidy Extension

About The Podcast:

Millions of Americans feel confused and frustrated in their search for quality healthcare coverage.

Between out-of-control costs, countless inefficiencies, a lack of affordable universal access, and little focus on wellness and prevention, the system is clearly in dire need of change.

Hosted by healthcare policy and technology expert Marc S. Ryan, the Healthcare Labyrinth Podcast offers accessible, incisive deep dives on the most pressing issues and events in American healthcare.

Marc seeks to help Americans become wiser consumers and navigate the healthcare maze with more confidence and certainty through The Healthcare Labyrinth website and his book of the same name.

Marc is an unconventional Republican who believes that affordable universal access is a wise and prudent investment. He recommends common-sense solutions to reform American healthcare.

Tune in every week as Marc examines the latest developments in the space, offering analysis, insights, and predictions on the changing state of healthcare in America.

About The Episode:

On this episode, Marc discusses the quiet talks on Capitol Hill on an enhanced subsidy extension.

Key Takeaways:

Quiet talks are occurring on Capitol Hill on the status of the enhanced Exchange subsidies.

During the COVID pandemic, the base premium subsidies were enhanced and will expire at the end of this year.

The enhanced subsidies significantly reduced expected premiums against the permanent law, especially at lower incomes.

At the same time, it removed the 400% poverty level cap on subsidies.

Negotiations are ongoing between the White House and moderate Republicans and Democrats in Congress.

While most Republicans oppose any extension, GOP leaders may have to bow to moderates' and swing district holders' demands. Democrats say they will not vote to reopen government unless the subsidy issue is addressed.

Without an extension, consumers would see an average increase of 114% from an average of $888 in 2025 to $1,904 in 2026. Millions could lose coverage due to affordability issues.

Individuals making $18,000 would pay $378 more a year, with individuals making $55,000 paying $1,469 more a year.

A family of four making $40,000 would pay $840 more a year, with a family of four making $110,000 paying $3,201 more.

Older, middle- to high-income adults are expected to face the largest dollar increases in premiums. Hikes will also vary by markets in each state.

On the table to get to a compromise are a short-term extension, an income cap on subsidies, minimum premiums for everyone, and allowing the enhancements only for existing enrollees.

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Resources:

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The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance