Archive | June, 2025

How artificial intelligence controls your health insurance coverage

21 Jun

Health insurers increasingly use artificial intelligence (AI) algorithms to determine which medical treatments and services will be covered, particularly through prior authorization, where AI evaluates whether a treatment is “medically necessary”. Insurers claim AI enables faster, safer, and more cost-effective decisions, potentially reducing unnecessary care. However, there are significant concerns about transparency, fairness, and patient impact.

A key issue is the opacity of these AI systems—insurers do not disclose how their algorithms function, making it difficult for patients and providers to understand or challenge decisions. When coverage is denied, patients face limited options: appeal (a process rarely pursued due to its complexity and cost), accept an alternative treatment, or pay out-of-pocket, often unaffordable. Evidence suggests that AI-driven denials can delay or block access to necessary care, sometimes with insurers financially benefiting if appeals outlast a patient’s prognosis. In other words, the patient dies during the appeals procedure.

There are also several equity concerns: people with chronic illnesses, minorities, and LGBTQ+ individuals are disproportionately affected by denials, and the use of AI may worsen these disparities. Regulatory bodies and lawmakers are beginning to address these issues, but the lack of knowledge about the algorithm and accountability remains a pressing problem for patient rights and health equity.

You can read a more detailed story here.

This is not a new concern: read a JAMA article from March 2024.

What can you do? – Join in the fight to create universal health care for everyone. Some helpful links:

One Payer States

Health Care for All Washington

Let me know your thoughts in the comments.

50,000 people suddenly lost healthcare insurance!

19 Jun

On June 17, 2025, this OP ED in the Seattle Times: “Patients hurt most by Aetna-UW Medicine contract failure” describes how 50,000 people suddenly lost their healthcare insurance coverage, and they had no recourse.  Read the story here:
https://www.seattletimes.com/opinion/patients-hurt-most-by-aetna-uw-medicine-contract-failure/

The Aetna-UW Medicine contract failure brings out the basic flaws in our current healthcare system, where profit motives and employment-based coverage create unnecessary barriers to care and disrupt critical provider-patient relationships. A universal healthcare system that is publicly funded but privately delivered would eliminate these disruptions and maintain the benefits of private healthcare delivery.

By ensuring all providers are “in-network,” decoupling coverage from employment, reducing administrative waste, and enhancing transparency, such a system would address the core deficiencies and improve access to care.  Until we fix it, the current healthcare system will continue to degrade healthcare by placing profit considerations above patient needs. A universal system would reorient healthcare around its fundamental purpose: ensuring everyone has access to the care they need, when they need it, without financial barriers or network disruptions.

In 2021 through Senate Bill 5399, the Universal Health Care Commission (UHCC) was set up to prepare Washington for universal coverage. In 2024 the results of three critical studies to develop infrastructure, unify the healthcare system, and meet federal waiver requirements projected savings ranging from $738 million to $12 billion annually while expanding benefits like vision, dental, and mental health services.

Every reader should urge their Washington legislator to tell the UHCC to publish their design for a universal healthcare system for all Washingtonians.

Find your legislator here: https://app.leg.wa.gov/districtfinder

I helped create Medicare Advantage. Here’s why I believe it needs reform.

17 Jun

An Architect of MA Speaks Out – In an op-ed published by The Hill on Sunday, former Republican Rep. Jim Greenwood of Pennsylvania — who helped write the Medicare Modernization Act that created Medicare Advantage — said plainly: “The program no longer lives up to [its] promise. I never imagined that Medicare Advantage would become a vehicle for such waste and abuse. It’s time to fix it.”

Read Jim Greenwood’s own words here.

Republicans Turn Against Medicare Advantage: A Growing Conservative Revolt

Republican leaders are increasingly criticizing Medicare Advantage (MA), marking a significant shift from traditional bipartisan support for the privatized Medicare program that now covers more than half of all beneficiaries.

Leading Conservative Voices

Former Republican Representative Jim Greenwood of Pennsylvania, who helped create the Medicare Modernization Act establishing Medicare Advantage, publicly declared that “the program no longer lives up to [its] promise.” Greenwood acknowledged that what was intended to drive innovation through private competition has been overtaken by “a handful of massive insurers who are gaming the rules for profit.”

Two Republican physicians in Congress, Representatives Greg Murphy of North Carolina and John Joyce of Pennsylvania, co-chairs of the GOP Doctors’ Caucus, wrote that “profit-driven insurance companies have destroyed [Medicare Advantage’s] model.” They specifically criticized insurers for using prior authorization to delay or deny necessary care and for “upcoding” – exaggerating patient illness severity to collect more taxpayer dollars.

Financial Impact

Medicare Advantage now costs taxpayers 22% more per beneficiary than traditional Medicare, according to the Medicare Payment Advisory Commission (MedPAC), resulting in $83 billion in overpayments to private insurers last year alone. This represents a dramatic departure from the program’s original cost-saving promise.

Industry Accountability

Conservative advocacy leader Phil Kerpen warned that Medicare Advantage is “becoming increasingly costly and unstable,” pointing to the Department of Justice’s criminal investigation into UnitedHealth as evidence of systemic problems1. He called for stronger disclosure rules, better plan comparison tools, and serious action against prior authorization abuse.

Political Implications

This Republican criticism represents a crack in the insurance industry’s protective wall of bipartisan political support, potentially opening the door for meaningful Medicare Advantage reforms that the insurance lobby has successfully fought for years.

What can you do? – Join in the fight to create universal health care for everyone. Some helpful links:

One Payer States

Health Care for All Washington

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How the hunt for profit can harm cancer patients

4 Jun

Cancer Drug Costs: High Prices, Modest Benefits

A new Bloomberg investigation reveals the troubling reality behind America’s $200 billion cancer drug industry, where pharmaceutical companies are generating massive profits from treatments that often fail to extend patients’ lives.

Exorbitant Costs Without Survival Benefits

Cancer drugs have reached staggering price points, with medications like Pfizer’s Ibrance costing $214,000 annually despite never being proven to prolong women’s lives[1]. The median initial price of new cancer drugs has quadrupled after inflation since the early 2000s to approximately $25,000 per month, while the average survival improvement is only about three months[1].

Flawed FDA Approval Process

The Food and Drug Administration has expedited approvals based on “progression-free survival” – a measure of tumor growth that doesn’t necessarily correlate with extended life[1]. Fewer than half of cancer drugs approved since 2000 have ever demonstrated survival benefits, yet they remain on the market generating billions in revenue[1]. In the past decade alone, drugmakers earned over $50 billion from cancer drugs showing no survival benefit[1].

Devastating Healthcare Costs

Medicare spending on oncology drugs more than doubled to $53.9 billion in just four years ending in 2020[1]. This explosive growth places enormous strain on the healthcare system and forces difficult coverage decisions that ultimately affect patient access to care.

Industry Regulatory Capture

Pharmaceutical companies have gained significant influence over the regulatory process by funding nearly half of the FDA’s $7 billion annual budget through user fees[1]. They also financially support patient advocacy groups, creating a network that promotes faster drug approvals with reduced scrutiny.

Broken Promise to Patients

Despite the proliferation of new treatments, overall cancer survival rates have shown minimal improvement[1]. Patients and families often assume newly approved drugs are “fantastic,” creating false hope when many offer little to no meaningful benefit while imposing substantial financial and physical burdens through toxic side effects[1].

You can read the full Bloomberg article by clicking the link below:

  1. https://www.bloomberg.com/graphics/2025-cancer-treatment-costs/

For an interactive description of the overall landscape of cancer in the US review this report published Dec 2024 by the  National Institute for Health Care Management (NIHCM) – a nonprofit, nonpartisan organization dedicated to transforming health care through evidence and collaboration.

What can you do? Advocate for a universal healthcare solution to end the scramble for profit in healthcare. Join in the fight to create a better healthcare system:
1. Health Care For All Washington – https://www.hcfawa.org
2. One Payer States – https://www.onepayerstates.org/

    Republican Strategy to Undermine the Affordable Care Act: A Stealth Approach

    3 Jun

    Republicans have adopted a significantly different strategy in 2025 compared to their failed 2017 “repeal and replace” efforts, implementing what healthcare experts describe as a stealth dismantling of the Affordable Care Act through legislative and regulatory changes that avoid direct repeal messaging while achieving similar coverage reductions.

    Strategic Rebranding: Avoiding Direct Repeal Language

    The primary Republican strategy involves carefully avoiding the inflammatory “repeal and replace” terminology that generated massive public opposition in 2017[1][2]. Instead, congressional Republicans are pursuing changes to the ACA that would result in 10.7 million fewer Americans having health insurance through marketplaces and Medicaid, while maintaining that they are not technically repealing Obama’s signature healthcare law[1]. This approach represents what Matt Salo, executive director of the National Association of Medicaid Directors, calls “a stealth repeal and replace” where “they’re being clever about it without using the term”[1].

    Targeting Core ACA Components Through Administrative Burden

    The second key strategy focuses on systematically weakening the twin pillars of Medicaid expansion and federally subsidized insurance marketplaces through increased administrative requirements and eligibility restrictions[1]. House Republicans have identified over $800 billion in savings over the next decade from Medicaid and marketplaces, with the Congressional Budget Office projecting that 7.6 million fewer individuals would be enrolled in Medicaid and 3.1 million fewer in marketplaces within a decade[1]. The proposal includes requiring states to verify Medicaid expansion eligibility every six months rather than annually, eliminating year-round enrollment for low-income marketplace participants, requiring additional documentation from applicants, and reducing the open enrollment period by one month[1].

    Justifying Cuts Through “Fraud and Waste” Messaging

    Republicans are framing their healthcare cuts as targeting inefficiencies, fraud, and ineligible recipients rather than legitimate beneficiaries[1][3]. The White House argues that reductions would primarily affect undocumented immigrants and able-bodied people who should not be on Medicaid[4]. Dr. Mehmet Oz, Trump’s CMS administrator, maintains there are “no cuts to Medicaid” and that proposals focus on work requirements to “future proof” the program[3]. However, reliable estimates show that fraud within Medicaid is primarily committed by providers rather than recipients, and the entities responsible for identifying fraud would receive no additional funding under GOP proposals[1].

    Financing Tax Cuts Through Healthcare Spending Reductions

    The underlying motivation for these healthcare changes stems from the necessity to fund extensions of Trump’s tax cuts through budget reconciliation[1]. The animosity toward the ACA among Republicans is secondary to their need to offset the costs of tax reductions, with the healthcare cuts serving as a primary funding mechanism for the broader “One Big Beautiful Bill”[5][6].

    This summary is directly from perplexity.ai.

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    1. https://www.washingtonpost.com/health/2025/06/02/shhh-republicans-are-trying-repeal-obamacare-again-sort/        
    2. https://kffhealthnews.org/morning-breakout/republicans-are-quietly-working-to-undermine-key-parts-of-obamacare/
    3. https://www.politico.com/news/2025/05/30/dr-oz-claim-gop-cutting-medicaid-00375618 
    4. https://thehill.com/policy/healthcare/5329416-democrats-criticize-trump-budget-medicare-cuts/
    5. https://www.politico.com/live-updates/2025/05/20/congress/gop-megabill-to-save-congress-nearly-800-billion-but-cut-coverage-00359606
    6. https://www.yahoo.com/news/mike-johnson-russ-vought-continue-162121425.html

    What is the impact of the current budget proposal passed by the US House on healthcare in Washington state?

    2 Jun

    The One Big Beautiful Bill Act (H.R. 1 in the 119th Congress), passed by the House of Representatives in May 2025, would significantly impact healthcare coverage in Washington State, potentially making it one of the most affected states in the nation. According to Congressional Budget Office (CBO) estimates, Washington faces particularly severe consequences due to its robust Medicaid expansion under the Affordable Care Act[1].

    Nationally, the CBO projects that 13.7 million more Americans will become uninsured by 2034 due to the bill’s provisions combined with the expiration of enhanced ACA premium tax credits[4][5]. Given Washington’s current uninsured rate of 4.7% in 2022—an all-time low—and the state’s heavy reliance on federal Medicaid funding, Washington residents would likely experience a substantial increase in the uninsured rate.

    Washington State could experience a dramatic 25% decrease in Medicaid enrollment, representing one of the steepest declines nationally[1]. With current Medicaid/CHIP enrollment at approximately 1.84 million Washingtonians as of October 2024[2], this translates to roughly 460,000 residents losing Medicaid coverage. The state would also face a 15% reduction in federal Medicaid funding, among the highest cuts in the country[1].

    The bill introduces several provisions that would disproportionately affect Washington residents. Work requirements for able-bodied Medicaid expansion adults, requiring 80 hours per month of work, volunteering, or school attendance, would be implemented beginning in 2026[3]. Additionally, the legislation mandates more frequent eligibility redeterminations every six months rather than annually for expansion populations, creating additional administrative barriers[3][1].

    The legislation would effectively reverse much of the coverage gains Washington achieved through aggressive Medicaid expansion and robust implementation of ACA marketplace provisions, potentially pushing the state’s uninsured population back toward pre-ACA levels.

    What can you do to help change this trend? Check out Health Care for All Washington and join the effort to make universal health care real in Washington!

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    1. https://www.kff.org/medicaid/issue-brief/allocating-cbos-estimates-of-federal-medicaid-spending-reductions-and-enrollment-loss-across-the-states/   
    2. https://www.healthinsurance.org/medicaid/washington/
    3. https://www.sheppardhealthlaw.com/2025/05/articles/federal-healthcare-legislation/house-passed-budget-bill-the-one-big-beautiful-bill-act-includes-major-changes-to-medicaid/ 
    4. https://www.kff.org/uninsured/
    5. https://www.kff.org/policy-watch/how-will-the-2025-budget-reconciliation-affect-the-aca-medicaid-and-the-uninsured-rate/

    How Primary Care and Community Organizing Can Bring Us Universal Health Care Now

    1 Jun


    by Ron Lovell, HCFA-WA Board Member

    At our May 2nd Wednesday Speaker Series, we heard an inspiring presentation by Dr. Michael Fine, writer, community organizer, family physician, and President of Primary Care for All Americans.  His talk was based on his experience with organizing primary care clinics in several cities in the eastern United States. Read on for a recap and/or view his complete presentation on our YouTube channel.

    First, Dr. Fine outlined the failures of the U.S. healthcare market, emphasizing poor health outcomes, high costs, and deep health disparities. He argued the root cause is inadequate access to robust primary care for all Americans, noting only 43% of adults have a meaningful primary care relationship. He highlighted primary care’s proven ability to reduce costs and improve public health, drawing comparisons to other essential community services like police, fire, and education.

    He then described successful community-based models (e.g., Scituate, Rhode Island) and advocated for building a social movement, starting locally, to ensure universal primary care. He detailed strategies such as community meetings, local workgroups, playbooks, and local funding. He stressed the need for a massive increase in primary care workforce and fairer reimbursement models, calling for a shift from fee-for-service to per-person payments.

    HCFA-WA volunteer Dr. John Sobeck led the Q&A Session. He was joined by Primary Care Innovator Dr. Garrison Bliss who addressed these questions:

    • the critical shortage of primary care providers and the need to expand training and residencies
    • the imbalance in reimbursement that drives clinicians away from primary care
    • panel sizes for sustainable primary care practice (ideally 300-500 patients per doctor).
    • funding models, including local government and employer-based approaches
    • concerns about cherry-picking patients and ensuring equitable access
    • the role of direct primary care and its affordability for communities
    • incentivizing new graduates to serve in underserved areas, including loan forgiveness and community support
    • collaboration between organizations (Health Care for All-Washington, Whole Washington) toward single-payer and universal healthcare goals

    Key Takeaways:

    • Universal primary care is essential, affordable, and achievable through community organizing.
    • The U.S. must address workforce shortages, payment reform, and health disparities.
    • Social movements, not just legislation, are needed to drive systemic healthcare change.
    • Ongoing community engagement, collaboration, and advocacy are critical for progress.

    For more details on Dr. Fine’s work, please see this additional resource: The Path to Health Care for All Starts with Community-based Primary Care

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