Healthcare Economics and Policy

With changes in the Medicare Advantage risk model, slowed increase in Medicare Advantage county base rates, and downward pressure on Medicare star ratings—we are seeing broad evidence of retraction. Altogether, these changes amount to a significant cut to industry revenue. National carriers are announcing major cost cutting initiatives, withdrawals from unprofitable markets, and markedly slashing member benefits in an attempt to stay profitable. And some health systems are taking the unprecedented step of exiting Medicare Advantage (many of them non-profit) altogether despite the fact that 50+% seniors now use the program to access healthcare services. Taken together, some are calling these cuts “the great disruption.” Some observations: 1) Benefit “innovation” had gotten out of hand. To stay competitive and grab share, plans (including ours) were introducing unsustainable benefits that caught attention of members only to pull them back. This is going to stop. At least for now. (Traditionally unsexy) Benefit stability will win the hearts and minds of beneficiaries who will be tired of the yo-yo benefits they have experienced in our previously inflationary environment. If it’s too good to be true, it usually is and startups that funded growth through investment capital can’t do it forever. 2) Organizations that succeeded in Medicare Advantage risk through maximizing revenue capture will actually have to learn how to effectively manage care for older adults. This means providing rapid access to patients to help them avoid emergency rooms and hospital admissions. This means more proactive management of chronic conditions. This means managing their own utilization of low-value services. It’s a worthy challenge and time for put so-called high value healthcare organizations to the test. 3) As benefits come down to earth and there’s more parity, competition will be increasingly focused on effectiveness and service. Do you actually do what you say will do? Does your rhetoric match action? And this is a good thing. Service excellence along the value chain is what matters most to beneficiaries. It just hasn’t been what they valued most at point of purchase. Organizations that commit to radical consumer focus will win. 4) Brokers will be more important than ever to guide people to make good decisions about their plans. In an increasingly complicated marketplace (made more complicated by the IRA and changes to drug benefits), people who can help seniors truly understand their options and true out of pocket exposure will be critical. 5) Everyone partnering with everyone (brokers, plans, provider partners) is not a winning strategy. Deeper, narrowing partnerships will win the day. The “great disruption” will begin to play out this Annual Enrollment Period. Let’s just not forget that at the other end of everything we do is an older adult who relies on our service and care.

After losing my dad to cancer, I became a cancer researcher at MIT – looking for answers. What I learned surprised me: it’s not the science that’s failing us. It’s the system that pays for it. A founder I know built AI that detects cancer on radiology scans earlier than any human can — early enough to cure it. He pitched a major health insurance exec: ✅ “Catch cancer early, when it’s cheaper to treat. Cut costs. Save lives. Everyone wins.” His reply? ❌ “We’ll never pay for it.” Why? 👉 “The average person switches jobs every ~2.5 years. We’d pay for the test and the treatment… But their next insurer would get the benefit.” Let that sink in. We’ve built a system where saving lives is a bad business decision. The root problem? Health insurance is tied to your job. Which means insurers think short-term. They have no reason to invest in your long-term health. But imagine if you owned your insurance — and took it with you job to job, like a 401(k). Suddenly, long-term thinking could win. Cancer rates are rising — especially in young people. We don’t just need better treatments. We need better incentives. It’s time to rewire the system: ✅ Where saving lives is good business ✅ Where insurers think long-term ✅ Where healthcare actually makes people healthy This isn’t theoretical. It’s personal. And it’s why I’m building Thatch.

💡 Unpaid care is the invisible backbone of Europe’s economy New data from the European Institute for Gender Equality (EIGE) shows that unpaid care work — including long-term care for older people, people with disabilities, and dependents — is essential yet undervalued. It’s time to shift how we see care: not a private burden but a critical public infrastructure.   🤝 Key insights from the CARE Survey 2024 & related findings: 🔹 Long-term care is overwhelmingly provided by informal carers — mostly family members — and remains largely unpaid and unrecognised, despite being essential for social and economic systems. 🔹 Women take on the lion’s share of intensive care responsibilities, limiting their access to paid work, career progression, and financial security. 🔹 Combining paid work with caregiving duties impacts wellbeing: carers often cut paid hours, slow career growth, or exit the workforce. 🔹 Formal long-term care services are still insufficient or unaffordable, meaning families bear the brunt of care needs that should be shared more equitably. 🔹 The CARE Survey 2024 is the largest EU-wide effort to date, covering over 65 000 respondents across all 27 Member States — offering a detailed picture of care realities and gender gaps. 📈 Why this matters: Investing in high-quality, affordable long-term care services is essential for: ✔ Dignified ageing and social inclusion of persons with care needs ✔ Closing gender gaps in employment and earnings ✔ Protecting carers’ economic security and well-being ✔ Supporting labour market participation ✔ Strengthening productivity and economic resilience 👥 Let’s redefine long-term care as a shared good and a key function of the social protection systems and build policies that support carers, enable shared responsibility, and unlock Europe’s full economic potential! #CareEconomy #GenderEquality #LongTermCare #WorkLifeBalance #EIGE #EUdata   For more: Sharing care, closing gender gaps: CARE Survey 2024 | European Institute for Gender Equality Unpaid care keeps Europe’s economies running, so let’s invest in it | European Institute for Gender Equality    The photo by Make Mothers Matter - MMM illustrates just perfectly the invisible backbone of our societies!

Your company will spend more on your health next year - but not out of kindness. A new global survey shows 67% of employers are increasing investment in preventive healthcare. Why? Because medical inflation is exploding, and companies are paying for it. The insurance premiums they pay for employees can jump by 10–20% per year. And the more employees claim insurance, the higher the cost goes. So now, companies are realising that prevention is cheaper than treatment. This means more wellness programmes (yoga, meditation), workplace environment changes (air purifiers, walking meetings), early screenings, and mental healthcare. A meta-analysis by Harvard researchers also found that : - Every $1 spent on preventive wellness saved $3.27 in medical costs - And also saved $2.73 in absenteeism and productivity loss So the message is clear: investing in prevention saves companies money, AND keeps employees fit for better work output. While companies may do this for economic reasons, I do think this is a win-win situation. - It helps you feel better, live better, be healthier - Mental health support is becoming a core part of plans - In India, cancer and heart disease are top priorities So overall, your risk of disease will decrease, and longevity will improve. It's a win-win situation. Is your company offering preventive healthcare yet? #healthandwellness #workplacehealth #lifestyle

Recommended reading! She RISES: a framework for caring cities Cities often mirror the inequalities embedded in society. She RISES: A Framework for Caring Cities, developed by surabhi tandon mehrotra, Kalpana Viswanath, Ankita Kapoor and Rwitee Mandal from Safetipin, brings this imbalance into sharp focus. It exposes how urban design and governance frequently overlook the gendered dimensions of city life, especially the invisible role of care work in sustaining urban systems. The framework is built around four core principles: Responsive, Inclusive, Safe and Equitable Spaces. Together they form an integrated approach to gender transformation through four streams of action. The first stream focuses on public spaces and infrastructure. Well-lit streets, obstacle-free pavements, safe public toilets and mixed-use neighbourhoods are presented as essential design features that enable women’s participation in urban life. The second stream addresses services and amenities, highlighting the need for childcare facilities, housing for single women, and access to affordable health care. Recognising and redistributing care work across communities, markets and the state is seen as a cornerstone of an equitable city. The third stream targets mobility and public transport. Women’s complex travel patterns, shaped by care duties and multiple destinations, require safe, affordable and well-connected systems. Gender-disaggregated data and inclusive recruitment policies in the transport sector are proposed as practical tools for change. The fourth stream concerns responses to gender-based violence, emphasising the implementation of existing laws, the establishment of crisis hubs, and public campaigns that reshape social attitudes. The She RISES framework is both analytical and operational. It is intended for planners, policy makers and urban managers who aim to embed gender sensitivity into every layer of urban governance. The report also serves as a reminder that the care economy is not peripheral but foundational to the functioning of cities. Safetipin, the social enterprise behind this work, has been collecting and analysing safety data in more than forty-five cities across Asia, Africa and Latin America. Their evidence confirms that cities designed with care in mind not only improve safety for women but also strengthen social cohesion and economic resilience for all. #GenderEquality #UrbanDevelopment #InclusiveCities #UrbanPlanning #PublicSpace #CaringCities

I am happy to co-author this article with Beatrice WEDER DI MAURO, President of the CEPR - Centre for Economic Policy Research, reflecting on the urgent need to engage in collective thinking and action to adapt our response to the challenge of insurability in the face of escalating climate risks. This article, which captures key convictions from our joint workshop hosted at Collège de France by the AXA Research Fund and CEPR - Centre for Economic Policy Research, couldn't have been more timely.   Devastating floods in Valencia, the wildfires in Los Angeles, the typhoons in Mayotte and La Réunion... These recent climate catastrophes show a clear reality: climate risks are intensifying and the protection gap for local communities and economies are becoming evident. Global economic losses from extreme weather events reached $320 billion in 2024, while in Europe, only 25% of economic losses were insured - leaving individuals, businesses, and communities vulnerable.    To address this, we need to enhance risk-sharing mechanisms and promote partnerships between public institutions and private companies.   Ensuring insurance accessibility and effectiveness is crucial. This can be done through: ➡️ Hybrid models, combining market mechanisms with public-private partnerships, to help ensure broad coverage and affordability. France’s CatNat regime and Switzerland’s hybrid model offer valuable insights. These models can be adapted to regions facing extreme exposure, such as sea level risks. ➡️ Greater investment in prevention and risk-sharing mechanisms. Initiatives like local municipal risk assessments can help small municipalities assess and mitigate local climate risks. ➡️ Impact underwriting, where insurers incentivize policyholders to adopt risk-reducing measures in exchange for lower premiums. ➡️ Public education on climate risks and stronger coordination between insurers, governments, and consumers to ensure preventive measures are taken seriously.   As we move forward, it's clear that policymakers, insurers, and society must work together to strike a sustainable balance between affordability and fiscal viability. This is not just about who pays the bill. It is about how we manage risk in an increasingly uncertain climate landscape. Let's continue to foster collaboration and innovation to close the protection gap and build a resilient future. 👇 https://lnkd.in/er6BkrtZ

A profit cap on insurers increased Medicare costs by $1.2 billion. New NBER research reveals how they did it. --- 💊The Affordable Care Act required Medicare Part D insurers to spend at least 85% of revenue on healthcare claims starting in 2014. ↳ This capped their profits at 15% through Medical Loss Ratio (MLR) requirements ↳ Payments to affiliated pharmacies count as healthcare costs in MLR calculations ↳ Pharmacy profits themselves remained unregulated For insurers who owned their own pharmacies, this created an opportunity to shift profit to other parts of the business. --- A new working paper (not peer reviewed yet) from the National Bureau of Economic Research provides us the data. The research compared what the same insurer paid affiliated vs. non-affiliated pharmacies for identical drugs. Vertically integrated insurers increased prices paid to affiliated pharmacies by 9.5% compared to non-affiliated pharmacies after MLR implementation. 🧢 For insurers most at risk of violating MLR requirements (those below 90%), the increases were even larger: ↳ 17.8% price increases to affiliated pharmacies ↳ Compare that to 2.9% for insurers with MLRs above 90% (i.e., they weren't worried about hitting the cap) --- Vertically integrated insurers shifted ~5% of their profits to affiliated pharmacies through this strategy. This increased Medicare Part D spending $1.2 billion from 2014-2016. 💸 25% of those inflated costs ($302 million) fell on parties outside the insurer parent company: ↳ Taxpayers (through Medicare): $259 million through higher federal reinsurance and subsidies   ↳ Patients: $22 million in increased out-of-pocket costs ↳ Drug manufacturers: $21 million in mandatory rebates --- This example highlights a regulatory challenge with vertical integration that I covered in a recent blog post https://drugch.nl/4mD8n3y When only one segment of a vertically integrated company is regulated, companies may shift profits to unregulated segments. The pattern applies beyond healthcare to any regulated industry with vertical integration. What's your response? 1️⃣ This is fine--no changes needed 2️⃣ Regulate the insurer and all vertically integrated segments 3️⃣ Remove regulation from insurers 4️⃣ Something else 📄 Working paper: https://lnkd.in/eC6DakSG ♻️ Repost to share the impacts of vertical integration. 🔔 Follow me for more insights on pharmacy economics and regulation (Bryce Platt, PharmD)

Where the alarms should ring is in the health benefits/insurance industry. I just did an interview in which I asserted, something I deeply believe, that these companies for the most part add only administrative costs and hassles to the healthcare industry and provide absolutely no value. Negotiated prices by insurers are often if not invariably higher than cash prices for the same procedures at the same places (see, for instance https://lnkd.in/gKk2UXaZ or do a search under the phrase are healthcare cash prices lower to find more evidence). Prior authorization has expanded in use even though the American Medical Association notes its effects to increase prices, red tape, and burdens on both healthcare providers and patients (https://lnkd.in/g_iAkgRQ). In fact, benefits administrators often deny payment of valid, even pre-authorized healthcare claims, further driving up costs and inefficiencies (see, for instance, https://lnkd.in/gBf66VEz.). Health insurers don't get better prices, don't improve access to care, and don't reliably even pay claims. In short, they add absolutely no value. One reason that the Kaiser health system is able to offer high quality at lower costs is because it is an integrated system that eliminates these third party administrators (https://lnkd.in/gUd9cnBE). Employers, when they use third party administrators, are for the most part NOT getting what they are paying for. They should change their purchasing behavior. #healthcare #KaiserPermanente #medicalcare #healthbenefits #healthcarecosts #healthinsurance #healthinsurers

Excited to share our new National Academy of Medicine report on how sex and gender identity influence disability evaluations by the Social Security Administration (SSA). We were commissioned by SSA & took part in a 1+ year process to report on the unique health challenges faced by Transgender and Gender Diverse (TGD) individuals, as well as those with Variations in Sex Traits (VSTs). We developed conclusions that could make for a more inclusive and accurate assessment process when people apply for disability benefits. **Key Takeaways:**   1️⃣ **TGD and VST Populations:** The report underscores that individuals from these populations often face significant barriers to healthcare, which can delay disease detection and worsen long-term health outcomes. These health disparities can directly impact their eligibility for disability benefits.     2️⃣ **Inclusive Language**, particularly for conditions like reproductive cancers and HIV: By removing gendered terms and focusing on the condition itself, disability evaluations can be inclusive for all individuals, regardless of gender identity. 3️⃣ **Data Collection:** Routine collection of data on gender identity, sex recorded at birth, and relevant care (e.g., gender-affirming treatments) is vital for an accurate evaluation. These data are lacking in many healthcare systems, but incorporating them into disability applications could help lead to more accurate determinations.  4️⃣ **Special Considerations:** The report highlights the need for careful evaluation of sex-specific diagnostic criteria for conditions like pulmonary function and kidney disease. In some cases, the sex recorded at birth may be the appropriate reference point, but in others—particularly for those receiving gender-affirming hormones—additional or alternative metrics may be necessary. One option is to use the measurement most likely to support an individual's disability application in cases where both 'male' and 'female' reference ranges are considered. 5️⃣ **Training for Disability Adjudicators:** Given the complexities in assessing disability claims for TGD individuals and those with VSTs, staff can receive training on the unique health and social challenges faced by these populations. This could ensure more accurate, fair, and compassionate disability determinations. By improving how disability claims are evaluated for TGD and VST individuals, we can move closer to a system that truly supports everyone. https://lnkd.in/egUKPbHT #SSA #HealthEquity #healthcare

Gender equality and disability inclusion are essential to creating societies where everyone has equal opportunities and access to resources. This document presents a structured approach to addressing the unique challenges faced by women and girls with disabilities, shedding light on systemic barriers such as discrimination, economic exclusion, and restricted access to education and healthcare. By focusing on participatory approaches, it ensures that those directly affected are involved in shaping solutions, fostering a more inclusive and representative decision-making process. Beyond identifying obstacles, the document provides concrete strategies for making development efforts more inclusive. It explores ways to dismantle harmful social norms, enhance service accessibility, and create economic opportunities that empower women with disabilities. Through real-world examples and evidence-based recommendations, it illustrates how inclusive policies and programs can lead to lasting improvements. The guide also highlights the role of strong legal frameworks and institutional accountability in sustaining progress. For those working to advance gender equality and disability rights, this resource serves as a practical tool for integrating inclusive principles into programs and initiatives. It offers step-by-step guidance on embedding accessibility, participation, and equity into various sectors. By prioritizing lived experiences and collaborative approaches, it reinforces the importance of ensuring that solutions are not only well-designed but also driven by the voices of those most affected.