A major study shows that investing in primary care and managing disease states could reap huge savings and improve outcomes.

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 major study showing investments in primary care and managing disease states could reap huge savings and improve outcomes.

Key Takeaways:

America spends the most on healthcare but has the worst outcomes.

One reason is the lack of focus on primary care and management of disease states.

America has huge inpatient costs due to admissions for uncontrolled conditions.

Forty-three percent of patients with diabetes and heart disease are not treated at all with evidence-based treatments and only 20% are treated adequately based on evidence.

Wakey Consulting finds that annual wellness visits (AWVs) can demonstrably help control costs among Medicare beneficiaries.

Wakley found that AWVs are considerably underutilized. About 45% of beneficiaries had just one or no such visits during the study period.

But showing how such visits can reduce costs and improve outcomes, Medicare beneficiaries who had 4 to 6 visits during the study period had lower inpatient and emergency department spending.

Those who received AWVs had an average $885 reduction in total costs per beneficiary per year. The $885 is almost 6% of Parts A and B spending in 2024.

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

As always at the end of the year, I recap healthcare happenings and tell you my predictions for the new year – just don't hold me to them!

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 healthcare happenings in 2025 and makes some predictions for 2026.

Key Takeaways:

It was a busy year in healthcare with insurer woes, a new president, and a decidedly different healthcare policy approach.

The One Big Beautiful Bill dominated a lot of the news in the first half of 2025. It led to a massive tax cut package that cut healthcare in Medicaid and the Exchanges by $1 trillion over ten years.

The government shutdown for a record 43 days over whether Exchange subsidy enhancements would be extended. So far, they were not.

President Trump laid out an aggressive drug price reform agenda and so far has gained a lot of concessions and is pressing on with most-favored-nation price reform.

There was an insurer meltdown that led to executive changes and massive realignment and contraction in the industry, especially in Medicare Advantage (MA).

A PwC report said that there would be huge digital investments and a move to personalized care. $1 trillion would be spent annually on the tech transformation in healthcare by the mid-2030s.

My 2025 prediction report card was pretty good. I correctly forecast deep cuts in healthcare, a healthcare shakeup by Trump, drug price reform, and the expiration of subsidies at year's end.

My 2026 predictions include a striking of drug tariffs by courts, another GOP healthcare bill, Congress and CMS pushing many MA reforms, and Democrats taking back the House in midterms.

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

Each year I help people make their open enrollment decisions. These stories tell us just how unaffordable healthcare is in America.

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 counseling he does to help people make their open enrollment decisions. These stories tell us just how unaffordable healthcare is in America.

Key Takeaways:

Each year I help many people make their open enrollment decisions.

One person just got a subsidy due to a quirk in the law in states that did not expand Medicaid under the Affordable Care Act. But the stats show that a reasonable Silver plan still costs over $800 per month for age 30.

One person's income will now mean he does not get any subsidy if the enhanced premium subsidies expire. He will pay about $20,000 in premiums for a family of two before and deductibles or cost-sharing.

I helped two elderly people find the right Part D coverage even with the major financial challenges in the program.

One person is 63 and desperately awaiting Medicare coverage. She relies on the Exchanges and given her income and age can only afford a Bronze plan with limited upfront coverage right now.

Statistics in the employer, Exchange, and Medicare worlds all show rising unaffordability of healthcare.

It is time to reexamine minimum essential benefits, provider pricing in healthcare, and how we think about comprehensive coverage.

Rich benefits ae useless if you cannot afford the policy or use the benefits.

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

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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Resources:

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