Category: Health and financial security

Daily GLP-1 pill could work as well as Ozempic
Rebecca Robbins and Gina Kolata report for the New York Times that a new pill to be taken each day could do as much to lower blood sugar and help with weight loss as Ozempic and Mounjaro, injectable weight-loss medicines. The FDA has not yet approved the pill for sale and is not likely to do so before next year.

What’s the value of Eli Lilly’s orforglipron pill? The pill conceivably could be cheaper than the current GLP-1 drugs because it costs less to manufacture a pill than an injectable drug. And, unlike an injectable, the pill does not need to be refrigerated or injected. The market for a GLP-1 pill is significant because many people do not want to inject themselves.

Lilly reports that, in a clinical trial, two-thirds of the 559 people who took the pill saw their blood sugar levels fall to the normal range. Lilly further reports that people who took the highest pill dose lost an average of 16 pounds.

But, it’s not yet clear whether the clinical trial data supports Lilly’s claims about the efficacy of its new pill. Side effects, such as diarrhea and nausea could be worse than claimed, and benefits could be smaller than claimed. Independent experts are not expected to analyze Lily’s data until June.

Axios reports that Lilly’s Zepbound, an injectable GLP-1 drug, delivered a greater amount of weight loss over 18 weeks for people without diabetes than people who took the pill. People had between 15.3 percent and 36.2 percent weight loss,, according to the data.

Today, one in eight Americans have taken a GLP-1. But, about four in ten Americans are obese. So, there’s a huge market for GLP-1 drugs.

N.B.: Medicare currently only covers weight-loss medicines for people with diabetes and heart disease. It does not cover these medicines for people who simply want to lose weight.

Here’s more from Just Care:
April 22, 2025
Funding cuts put community health centers at risk
Thousands of federally-funded community health centers throughout the country deliver free and low-cost outpatient services to tens of millions of uninsured and lower-income Americans each year. Historically, Democrats and Republicans in Congress have supported these centers. But, now, the Commonwealth Fund reports that Congress has put these centers on the chopping block and many might not survive.

Community health centers (CHCs) provide a range of health care services, including primary care, chronic care management, behavioral care, maternal care, and dental health care to more than 31 million Americans every year. CHCs are there for people who cannot afford to pay privately for their basic health care needs and people who live in rural communities without private health care providers. They offer cost-effective care to people who cannot pay high health care costs.

CHCs provide high-value care, which is what the Trump administration says it wants in our health care system. A Congressional Budget Office analysis last year found that additional government investments in CHCs could save Medicare and Medicaid billions of dollars.
Unfortunately, recently, both the Trump administration and Congress have been cutting CHC funding. Grant funds to CHCs have been frozen, forcing some CHCs to close and others to fire staff. In addition, Congress reduced CHC funding to $4.26 billion from $4.4 billion, even though there are more CHCs and more patients using them.

Moreover, if Congress cuts Medicaid, as appears to be the desire of the majority of Republicans, CHC revenues will take a big hit. Medicaid dollars represent more than 40 percent of CHC revenue.

Even before the administration and Congress began cutting funding to CHCs, many experts projected that CHCs would not have the resources needed to meet community needs. CHCs have been seeing more people who are uninsured or who are unable to pay for their care.

Here’s more from Just Care:

Congress must protect our community health centers

Senator Sanders wants greater US investment in community health centers

Protect your eyesight: Free and low-cost vision care

Roundup: Planning for life’s curve balls

2025: Programs that lower your costs if you have Medicare
April 21, 2025
Poll: Costs remain a major barrier to care
When you’re looking at people’s opinions about health care, it’s important to keep in mind that 85 percent of adults in the US say that their health is good or better than good. These people tend to be satisfied with their health insurance because they use it relatively little. Still, a lot of Americans remain concerned about high health care and prescription drug costs and medical bills, according to recent Peterson-KFF polling.

Forty-five percent of adults in the US are worried about their ability to pay medical bills. Twenty-eight percent of adults said that they delayed or went without care because of the cost. Eleven percent struggled to pay medical bills. And, 11 percent said that they did not have a usual source of care.

Adults who were uninsured, in poorer health, Black adults, and Hispanic adults, were much more likely to forego or postpone care because of the cost than others. Thirty-six percent of Hispanic adults, 32 percent of Black adults and 25 percent of white adults said they delayed or went without care because of the cost, underscoring health care inequities.

Of course, the uninsured generally face higher out-of-pocket costs than people with health insurance. And, people with lower incomes struggle more than people with higher incomes to cover insurance deductibles and copays.

Twenty one percent of adults said they went without dental care because of the cost. Sixteen percent said they went without mental health care, drugs or medical care because of the cost.

Likely because Medicare tends to provide better financial protection from health care costs than employer coverage and coverage on the state health insurance exchanges, fewer older adults delayed or went without care than adults under 65. One in five adults over 65 said they delayed or went without care because of the cost. Three in ten adults under 65 said they delayed or went without care because of the cost.

Here’s more from Just Care:
April 16, 2025
Improving our food would improve our health
Back in January, the Food and Drug Administration (FDA) proposed a rule that would change food labeling in ways that could improve our health. More recently, Secretary of Health and Human Services (HHS), Robert F. Kennedy Jr., proposed that the FDA reconsider its rule permitting substances Generally Recognized As Safe into our food. Will these changes happen and, if they do, will they improve our health?

Both the HHS and the FDA say they are committed to helping Americans know exactly what’s in the food they are eating. Eliminating substances “Generally Recognized As Safe” (GRAS) from our food supply would be a huge step towards achieving this goal. GRAS tend to be chemicals in our food, about which we know very little, if anything. They might not be safe.

Eliminating GRAS from our food would also make it easier for the FDA to oversee our food supply. “For far too long, ingredient manufacturers and sponsors have exploited a loophole that has allowed new ingredients and chemicals, often with unknown safety data, to be introduced into the U.S. food supply without notification to the FDA or the public,” said Secretary Kennedy. “Eliminating this loophole will provide transparency to consumers, help get our nation’s food supply back on track by ensuring that ingredients being introduced into foods are safe, and ultimately Make America Healthy Again.”

But, Kennedy is cutting 20 percent of the FDA’s workforce, reports Christina Jewett for the New York Times. Consequently, 3,500 fewer people are ensuring our food safety and medical device safety, approving new drugs, preventing outbreaks of foodborne illnesses, and much much more. Without strong FDA oversight, there’s much to fear about the safety of our food and health care.

Moreover, the FDA will face strong pushback from the food industry. Today, the food industry can simply inject substances GRAS into foods without even letting the FDA know. Companies can self-affirm that new ingredients in foods are safe. If RFK Jr. prevails, food companies would have to notify the FDA of their plan to use GRAS substances in their foods and provide the FDA with whatever safety data they had before they could use these substances.

Meanwhile, prior to President Trump taking office, the FDA issued a proposed rule that would require companies to put nutrition labels on the front of food packages to help Americans better understand the ingredients in their foods. The rule would change nutrition labels so that they reflected whether a product has low, medium or high levels of sodium, and saturated fat, reports Sarah Todd for Stat News.

If finalized, the nutrition labeling rule might might lead food companies to produce healthier food. The FDA, under the Biden administration, claimed that the rule would help fight chronic disease, including cancer and diabetes. These diseases are associated with diets that are high in saturated fats, salt and added sugars. Four in ten Americans have two or more chronic conditions and six in ten have at least one chronic condition.

Here’s more from Just Care:

Diet soda: Bad for your health and your weight

Can RFK Jr. limit harmful chemical additives in our food supply?

Live longer, avoid ultraprocessed foods

Is sugar addictive?

Stay healthy: Avoid foods that cause inflammation
April 15, 2025
Medicare Advantage costs and prior authorization rules impede access to care
Medicare Advantage costs and prior authorization rules continue to impede access to care. Anyone enrolled in a Medicare Advantage plan–Medicare coverage administered by a corporate health insurer–should be concerned about whether they will be able to get and afford the care they need if they get sick. Traditional Medicare provides coverage for care from almost any physician or hospital in the US without the need for prior authorization.

Jakob Emerson reports for Beckers Payer that typical deductibles for Medicare Advantage plans are now more than twice what they were in 2024. It’s fair to assume that they will continue to rise, given the Trump administration’s full court press on government spending. You’ll be fine in Medicare Advantage if you’re healthy, but you’ll likely be far better off in traditional Medicare if you want to ensure you’ll be able to afford and receive the care you need when you get sick.

Average Medicare Advantage deductibles were about $132 in 2024 and are now $315, according to an eHealth survey. That’s a 139 percent increase. Monthly premiums average just $5 a month this year, down from $9 in 2024. And, total out-of-pocket costs for covered in-network services can be as high as $9,350 this year, depending upon the Medicare Advantage plan.

Average Medicare Part D prescription drug coverage premiums are also up, from $29 to $36, about 25 percent.

Meanwhile, prior authorization rules remain another obstacle to care for Medicare Advantage enrollees, particularly those who need costly and complex care. Rylee Wilson reports for Beckers Payer that some states are looking into regulating insurers’ use of prior authorization. They are especially focused on insurers’ use of artificial intelligence or AI to determine whether a procedure should be covered and want a physician to oversee those decisions. (Could that simply mean a physician rubber-stamping them?)

Patients are currently suing UnitedHealth and Humana for using AI to deny rehab care in Medicare Advantage inappropriately. UnitedHealth spokespeople argue that they do not use AI exclusively to make coverage decisions. They might not, though having a provider oversee these decisions with financial and other incentives to approve them is no better than using AI exclusively.

Last year, the Centers for Medicare and Medicaid Services, CMS, which oversees Medicare, issued guidance on the use of AI in Medicare Advantage. CMS did not ban the use of AI or even restrict it. It simply said that the AI algorithm must comply with Medicare’s coverage requirements. Good luck enforcing that rule.

Dr. Mehmet Oz, who will head of CMS, once confirmed, believes in AI as a tool for expediting prior authorization decisions–seemingly, even though they can speed up inappropriate denials. However, Oz says that insurers should not use AI for more than 1,000 procedures.“I would argue that to use AI wisely, we would make a decision which is we’re only going to pre-authorize 1,000 procedures,” he said at a recent Senate hearing. Where he pulled the 1,000 number from is anyone’s guess.

Here’s more from Just Care:
April 1, 2025
How much profit should shareholders reap from health care?
A group of Yale researchers looked at where all the profits from the health care industrial complex flow. They found that the vast majority of money earned by pharmaceutical corporations, for-profit hospitals, health insurers and other publicly traded companies went to corporate shareholders, reports Sujata Srinavasan for Connecticut Public Radio.

In the 21 years between 2001 and 2022, the researchers found that $2.6 trillion went to shareholders. Their study is published in JAMA Internal Medicine. The number is shocking for at least three reasons. First, the $2.6 trillion represents 95 percent of the profits. Second, only five percent of the money went to medical research and development, improved hospitals or pharmaceutical research. Third, the returns to shareholders more than tripled over that period.

Given how much Americans pay for health care and the burden of medical debt on millions of us, it’s time for the government to rein in the prices we are being charged or, at the very least, limit corporate profits with the goal of lowering costs. Today, about 12 percent of adults in the US owe more than $10,000 in medical debt. Should there be a limit on corporate profits to reduce health care costs?

With increasing vertical integration in health care, e.g. UnitedHealth owning providers, a pharmacy benefit manager, claims processing centers, insurance companies and more, unless there is a limit on corporate profits, it’s more than likely that health care costs will continue to mount. Health care corporations are not putting patients first.

Corporate shareholder returns are not the only funds being stripped out of our health care system and driving up costs. The researchers did not look at the $1 trillion that private equity firms invested in health care over the last decade. These companies have destabilized a large number of hospitals, taking out profits and leaving them in major debt. They have also profited wildly from investments in home care agencies at the expense of older adults.

Here’s more from Just Care:
April 1, 2025
DOJ takes on health insurers for price-fixing
In a significant move, the DOJ filed a “statement of interest” in federal court this week, siding with hundreds of physicians who accuse top insurers and a firm formerly known as MultiPlan — now rebranded as Claritev — of conspiring to fix prices for out-of-network care.

The DOJ’s involvement doesn’t just add legal firepower. It sends a signal that this case matters. More importantly, it casts a harsh spotlight on how major insurers including UnitedHealthcare, Aetna, Cigna and Elevance may have skirted antitrust laws through a so-called “third-party intermediary” — and whether Wall Street has been too confident in the impunity these corporations usually enjoy.

According to reports, the DOJ rebuffed Claritev’s argument that there was no price-fixing conspiracy simply because insurers may use the company’s algorithm differently. The Sherman Antitrust Act, the DOJ pointed out, is clear: even setting a “starting point” for prices — if done in coordination — can be anti-competitive. And sharing sensitive pricing data through a middleman? That’s also potentially illegal.

As someone who spent years inside the health insurance industry, I can tell you that what’s at stake here is nothing short of enormous. If this lawsuit proceeds, we might finally get a clearer picture of how these corporations — working together under the cover of a “neutral” analytics firm — manipulated payment rates to increase profits, all while starving frontline health care providers.

Claritev and its insurer partners, of course, deny the allegations and have moved to dismiss the case. But the DOJ’s filing now stands in their way.

Some history: The backstory adds even more weight to the DOJ’s action. In 2023, a New York Times investigation uncovered how Claritev (then MultiPlan) operated under a perverse incentive: the more it “saved” insurers and their corporate clients by underpaying doctors, the bigger the cut Claritev and insurers took for themselves. That same year, Senator Amy Klobuchar called on federal regulators to investigate what she and many providers viewed as algorithm-enabled price-fixing. She even introduced legislation to stop corporations from using AI tools to coordinate pricing.

The DOJ statement of interest comes just weeks after the agency launched an investigation into UnitedHealth Group’s Medicare billing practices. As the Wall Street Journal reported, the DOJ “is examining the company’s practices for recording diagnoses that trigger extra payments to its Medicare Advantage plans, including at physician groups the insurance giant owns.”

For years, insurers have been able to hide behind complex data systems, AI algorithms and opaque contracting practices to squeeze providers — and boost profits. Investors have generally assumed that neither Congress nor federal regulators would seriously challenge that model.

But this latest move by the DOJ suggests otherwise. Maybe — just maybe — the Trump Administration will be tougher on insurers than investors expected. And if that is true, it would be a long-overdue course correction – for doctors, patients and taxpayers.

[Note: This post was originally published on Wendell Potter’s Substack, HEALTH CARE un-covered.]

Here’s more from Just Care:
March 31, 2025
UnitedHealth overbills the VA by hundreds of millions of dollars
At a recent Congressional hearing in Washington, Rep. Mark Takano (D-California), the top Democrat on the House Veterans Affairs Committee, directed a series of questions to the CEO of the health care company Optum, a wholly owned subsidiary of UnitedHeath Group. The exchange helped expose an alarming and growing problem in veterans’ health care in this country: massive overbilling by large, for-profit insurance conglomerates.

Takano’s questioning was a master class, and you should watch it. You can see a taste of it here.

What Rep. Takano exposed is that massive health care companies are enriching themselves at the expense of our nation’s Veterans.

At issue is the Veterans’ Community Care Program, which facilitates medical care for veterans provided by health care professionals outside of the Veterans Health Administration (VHA).

The program is administered by big health insurance companies, including Optum and TriWest. Data compiled by federal investigators shows that these insurers, often called third-party administrators (TPAs), overbill the government in a similar way that insurers selling Medicare Advantage plans do, as HEALTH CARE uncovered has reported.

Department of Veterans Affairs Office of the Inspector General (OIG) February 2025 report.

The investigators looked under the hood of these companies and found some real troubling signs. Their February 2025 report – published by the Department of Veterans Affairs Office of the Inspector General (OIG) – found that the VHA overpaid its TPAs by more than $1 billion between 2020 and 2024.

The largest recipient was UnitedHealth Group’s Optum, which received overpayments of more than $105 million from 2020 to 2022. TriWest was overpaid $73.4 million from 2020 to 2023. The OIG found the overpayments were a result of the companies charging the VHA incorrect rates.

For example, Optum reportedly overcharged the VHA by $783.4 million between 2020 and May 2024 for dental services provided by community care providers. Investigators said Optum was able to charge the extra amount because of a technicality in the contract: there was no language that specifically prevented Optum from charging the VHA more than it was reimbursing the community care provider for the service.

It turns out this is not a new problem. An OIG report from 2021 found that providers providing care for veterans through the Community Care Program billed for higher paying evaluation and management services codes at much higher rates than other doctors in the same specialty. That’s evidence of upcoding. The report also found that providers were potentially double billing for services provided by entering additional codes already covered by a global surgery code. These additional codes cost the VA $59.6 million from between 2020 and 2022.

Kudos to Rep. Takano for raising this important issue and his efforts to protect the integrity and solvency of the VA program and hold the insurance companies accountable.

[This post was originally published on March 18, 2025 on Health Care un-covered.]

Here’s more from Just Care:
March 19, 2025
Warning: Your medical debt will likely continue to appear on your credit report
During the Biden Administration, the Consumer Financial Protection Bureau (CFPB) passed a rule banning credit agencies from including medical debt on people’s credit reports. The final rule was set to go into effect on March 17, 2025. But, Evan Weinberger reports for Bloomberg Law News that Republicans in Congress are working to repeal this consumer protection.

Congressmen from South Dakota and South Carolina aim to ensure the CFPB rule never goes into effect. They call it “irresponsible and a clear example of regulatory overreach.” They have the power to repeal the federal rule with a simple majority vote.

As of now, President Trump delayed the rule’s start date. Moreover, a federal judge in Texas ruled in favor of a credit reporting agency group to delay the start date until June 15 unless Congress or the CFPB repealed it before then.

The CFPB rule improves credit scores by around 20 points. According to the CFPB, around 15 million Americans have medical debt totaling $49 billion. That’s likely a conservative estimate. Others have reported that older adults alone owe $54 billion in medical debt.

The rule’s repeal would make it harder and more expensive for people with medical debt to get credit. The Congressmen who oppose this consumer protection argue that banks and others who make loans cannot make informed decisions about whether a person is creditworthy if this CFPB rule goes into effect.

Here’s more from Just Care:
March 17, 2025
Will Trump give his supporters the lower health care costs they want?
As we know, Trump supporters, like most Americans want to see lower prices on basic necessities, like gas and eggs. They also want to see lower health care costs, reports Noam Levey for NPR.

What could Trump do? He could lower the out-of-pocket maximum on health care costs for working people. But, that would also likely drive up people’s premiums. And, the Republicans opposed the new $2,000 a year maximum on outpatient prescription drug costs for people with Medicare.

But, the polls indicate that, unlike 10 or 15 years ago, a lot of Trump supporters now want more government involvement to rein in health care costs. People recognize that the “free market” for health care is not their friend. People no longer think that government should stay away.

In fact, Republicans want the government to step in and limit drug prices and hospital charges. They also want the government to regulate and restrict health care providers from going after medical debt according to recent polls. More than eight in ten support a $2,300 annual cap on medical debt collection.

Republicans still don’t support Medicare for all. In fact, that would do most to lower their health care costs and ensure they received the health care they needed. One size fits all means that it works for everyone. Other options will not work for people in some or more instances, and there’s no telling when you buy insurance whether that restriced insurance coverage will work for you over time.

Republicans also overall support Medicaid. Medicaid is especially critical for lower and middle income older adults who need long-term nursing home care. Yet, the House Budget resolution puts in place a plan that will likely slash Medicaid spending and with it push many people off Medicaid.

Today, Republicans more often hold corporate health insurers, pharmaceutical companies and hospitals responsible for high costs than the government. They see the greed and profiteering in our corporate health care system.

One poll shows that 75 percent of people who voted for Trump want the government to limit hospital charges. They also want the Trump administration to do more Medicare drug price negotiation, not less.

Right now, Republicans in Congress are not focused on any of their supporters’ cost-cutting health care priorities. They are poised to slash Medicaid and end subsidies for plans in the state health insurance exchanges, both of which will drive up health care costs for millions.

Here’s more from Just Care:
March 5, 2025