Episodes

  • 92. My Biggest Worry … Erosion of Coverage

    92. My Biggest Worry … Erosion of Coverage
    Sep 12 2025
    A combination of events come together to create a worrisome erosion of coverage in the next decade, driving up both the uninsured and underinsured counts. 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 worrisome erosion of coverage in the next decade, driving up both the uninsured and underinsured counts. Key Takeaways: Two forces are coming together to further erode coverage in America. They are surging utilization and the OBBBA. Some of the surging utilization can be explained – a return to normal post pandemic utilization, increased expensive drug introductions, aging and more. But some of it cannot. While healthcare actuaries anticipate a slowing of annual healthcare growth in a few years, I think we could be in a new era of even more robust annual growth. When utilization spikes, as much as employers try to protect employees, more costs are foisted upon them or coverage evaporates. While the GOP says no one will lose coverage unless it is fraudulent or they want to be tossed, we know this is far from the truth. With the expiration of Exchange premium enhancements, 15 million will lose coverage in Medicaid and the Exchanges. We have seen very low uninsured rates due to coverage expansion. That will increase dramatically through 2034. The bigger problem could be the rise in the underinsured rate. Surging utilization, costs, and the fallout from the OBBBA will mean more and more fall into the ranks of the underinsured. Latest statistics say about 8% to 9% of adults are uninsured, 12% had a gap in coverage over the past year, and 23% were underinsured (they had coverage for a full year that didn’t provide them with affordable access.) We are in a crisis. It is clear that the uninsured and underinsured rates will rise because of misguided policies and the lack of true healthcare reform. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL’s Newsfeed THL’s Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    15 mins
  • 91. What Will Happen to Medicare Advantage in 2026?

    91. What Will Happen to Medicare Advantage in 2026?
    Sep 5 2025
    Given the major MA retrenchment in 2025, many are asking what will happen to offerings, geographies, and growth in 2026. I tell you. 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 what will happen to offerings, geographies, and growth in Medicare Advantage in 2026. Key Takeaways: Since January 2020, MA enrollment has grown from 23.93 million to 35.44 in July 2025, a growth of 11.51 million. From January 2020 to January 2024, average growth was 10%, ranging from 6% to 11%. Growth from January 2024 to February 2025 did come down considerably to 4.4%. Since February, MA continues to grow at a healthy pace overall. Between February and July, almost 500,000 lives were added to the MA rolls. We are likely in store for a rate of growth from 2025 to 2026 that is similar to 2024 to 2025. It is clear that the major retrenchment by MA plans in 2025 impacted overall growth. But a great value proposition compared with the traditional program sustains growth. 2025 brought a reduction in some added benefits, a major contraction of the Preferred Provider Organization (PPO) product, and geographic contraction. While many plans pulled back, national MA plans struggled the most in terms of benefit cuts, contraction, and growth. While Individual MA plan offerings declined by 6.54% in 2025, SNP offerings increased 8.5% in 2025. And SNPs have grown considerably since January 2024. In the end, robust competition remained, $0 premiums prevailed, and most enrollees could find very favorable plans. Some analysts are speculating that contraction of benefits, products, and geographies could be robust again this year. But will it be as big as 2025? I do not expect the enrollee impacts to reach what we saw in 2025. But based on recent announcements from United and Aetna, we can say the contraction in benefits, products, and footprint could again be sizeable in 2026. Connect With Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL’s Newsfeed THL’s Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    22 mins
  • 90. What Explains The Insurer Meltdown?

    90. What Explains The Insurer Meltdown?
    Aug 29 2025

    While outside forces contributed, health plans, especially the big ones, can blame their own mismanagement on the insurer meltdown.

    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 financial crisis of health plans. While outside forces contributed, health plans, especially the big ones, can blame their own mismanagement on the insurer meltdown.

    Key Takeaways:

    Outside forces contributing to the meltdown were high utilization and government actions that reduced rates and revenue and limited cost-savings opportunities.

    But health plans generally and the big plans specifically missed the financial mark.

    Big plans were over-zealous and had a severe lack of financial discipline.

    In Medicare Advantage, health plans ignored lower rates, lower Star performance, risk adjustment reform demands, and prior authorization limits.

    In Medicaid, plans grew too much, ushered on by what were temporary rules expanding growth and reimbursement.

    In the Exchanges, insurers did not plan for the eventual phaseout of enhanced premium subsidies.

    In the employer and commercial world, health plans did not respond to demands for cost-savings and greater transparency by insurers.

    The current trends, including the budget reconciliation bill, likely would have meant further retrenchment in all lines of business.

    But it is equally true that the lack of financial discipline by most of these plans in the last several years complicates their recovery.

    Connect With Marc:

    Marc on LinkedIn

    Marc on Twitter

    THL Podcast

    Resources:

    THL’s Newsfeed

    THL’s Blog

    The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    23 mins
  • 89. Direct Primary Care and Other Employer Coverage Reform

    89. Direct Primary Care and Other Employer Coverage Reform
    Aug 22 2025

    Direct Primary Care and other reforms could save employer coverage.

    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 Direct Primary Care model and other potential reforms to employer coverage.

    Key Takeaways:

    Direct Primary Care was boosted in the recent budget reconciliation bill.

    DPC is a healthcare model (not insurance) where patients pay a recurring, fixed fee directly to a primary care physician for access to a defined set of services.

    Opponents see DPC as limited and nowhere near comprehensive coverage, but it can be teamed with a high-deductible health plan (HDHP).

    Many employees struggle to afford employer offerings and a DPC with an HDHP could create a cost-effective yet robust option.

    Under the budget bill, DPC account holders can utilize their HSAs to pay for DPC service arrangement fees.

    DPCs will grow both individually but also as an employer offering.

    Smaller employers may look to DPCs with HSAs and HDHPs to lower their costs as well as those of employees.

    Employer coverage costs have been growing profoundly the past several years.

    Employers are increasingly frustrated with health plans and PBMs as relationships are not transparent. Plans and PBMs operate within black boxes.

    A new bill could bring unprecedented transparency to employer coverage by mandating sweeping reporting and data sharing with employer groups.

    The bill would promote competition and empower employers during negotiations.

    Connect With Marc:

    Marc on LinkedIn

    Marc on Twitter

    THL Podcast

    Resources:

    THL’s Newsfeed

    THL’s Blog

    The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    21 mins
  • 88. House MA Hearing Shows What's In Store For Insurers

    88. House MA Hearing Shows What's In Store For Insurers
    Aug 15 2025
    A recent House hearing on Medicare Advantage shows what is in store for plans. It may not be good. 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 recent House hearing on Medicare Advantage and what may be in store for plans. It may not be good. Key Takeaways: Capitol Hill has become far more active on MA issues, although major reform legislation has yet to pass. Democrats spoke of their usual gripes – overpayments MA and the need to augment the traditional Medicare fee-for-service (FFS) program. Republicans, who generally supported the program, were on board for many of the same reforms Democrats proposed. Lawmakers want action on MA overpayments. Lawmakers complained that supplemental benefits are not truly being spent on enrollee care. Lawmakers and MA executives pitched the idea of multi-year enrollment to stop marketing abuse, high expenses, and to promote care management. PA and claims denials were cited as the biggest concern by providers. Some argued that value-based care (VBC) payment mandates could promote the recovery of independent primary care practices. Some lawmakers feel the largest plans are abusing the system and giving the program a bad name. A number of bills have been filed to respond to these concerns. MA actually saves both Medicare and consumers quite broadly, and quality is markedly better. It is ironic that CMS now wants to introduce PA in the traditional Medicare program, arguing FFS is wasteful. Show Links: AHIP blog Better Medicare Alliance website Better Medicare Alliance statement Elevance Health Public Policy Institute Study Connect with Marc: Marc on LinkedIn Marc on Twitter THL Podcast Resources: THL’s Newsfeed THL’s Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    20 mins
  • 87. 2024 Medicare Advantage and Part D Program Audit Enforcement Report Out: What Does It Tell Us?

    87. 2024 Medicare Advantage and Part D Program Audit Enforcement Report Out: What Does It Tell Us?
    Aug 8 2025

    CMS’ Medicare Advantage (MA) program audits are getting tougher and more detailed every year.

    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 Medicare Advantage compliance. CMS’ program audits are getting tougher and more detailed every year.

    Key Takeaways:

    Overall, CMS’ program audit protocols are fair and reasonable. They hold plans accountable for the delivery of care to Medicare beneficiaries.

    There are four core audit protocols and a fifth for Special Needs Plans.

    The 2023 and 2024 program audit report shows MA audits are getting tougher and more detailed.

    Compliance Program Effectiveness is closely being scrutinized due to concerns about oversight of delegated vendors.

    Formulary Administration is also an active area due to concerns on correct prior auth edits, claims configuration, cost-sharing, and transition fills.

    Scrutiny of medical service and drug authorizations and appeals remain very detailed, with clinicians digging deep into cases and determination of medical necessity.

    On Special Needs Plans, CMS is always concerned about health risk assessments but is now going beyond that to determining if care plans are addressing all of the identified needs of individuals.

    CMS says plans are implementing and carrying out the new utilization management rules, but scrutiny should increase in the future.

    Financial audits are also increasingly rigorous and focused on no beneficiary harm.

    Record civil monetary penalties were levied in 2024.

    Connect with Marc:

    Marc on LinkedIn

    Marc on Twitter

    THL Podcast

    Resources:

    THL’s Newsfeed

    THL’s Blog

    The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    38 mins
  • 86. Will The New 100% RADV Audits Be Fair To Medicare Advantage Plans?

    86. Will The New 100% RADV Audits Be Fair To Medicare Advantage Plans?
    Aug 1 2025

    While justified, there is some question about whether the new RADV audits will be fair to MA plans.

    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 new 100% RADV audits. While justified, there is some question about whether the new RADV audits will be fair to MA plans.

    Key Takeaways:

    CMS announced it will audit all Medicare Advantage (MA) contracts for each payment year. How it will ramp up staff and technology to hit the aggressive announcement is another question.

    Opponents of MA call out dubious numbers on the magnitude of overpayments, but there is some risk adjustment abuse by a small number of plans that disproportionately benefit.

    About half of contracts have been noticed for RADV audits in payment year 2019.

    The 2023 RADV rule is controversial and being challenged by plans. The new audit process adds to the controversy.

    CMS will use a suspect approach and target diagnosis codes for HCC risk adjustment clusters most at risk of abuse.

    Fewer records can now be submitted, which ups the ante on accuracy, timeliness, and completeness during the submission period.

    The suspect sample audit approach and extrapolation of penalties should be a major concern.

    Will the industry end up worse off with the suspect approach than a more comprehensive one?

    Does the government now conduct RADV audits in an Elon Musk, “DOGE-like” approach, storm-trooping for maximum recoupment to hit lower spending targets rather than a fair and transparent process rooted in real program integrity?

    Other reforms could also be implemented.

    Connect with Marc:

    Marc on LinkedIn

    Marc on Twitter

    THL Podcast

    Resources:

    THL’s Newsfeed

    THL’s Blog

    The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    40 mins
  • 85. Healthcare Developments Beyond The One Big Beautiful Bill

    85. Healthcare Developments Beyond The One Big Beautiful Bill
    Jul 25 2025

    The Big Beautiful Bill buried some other important healthcare developments.

    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 other major healthcare developments that got buried by the One Big Beautiful Bill the past two months.

    Key Takeaways:

    The Big Beautiful Bill buried some other important healthcare developments.

    Health plans committed to significant prior authorization reforms.

    CMS will not propose further reforms right now as it monitors health plan implementation.

    Plans will reduce the number of PAs required and pursue electronic processing, some in real time.

    Numerous state and federal restrictions are already in place and the new commitments will hurt plans’ ability to control medical expense.

    CMS Administrator Dr. Mehmet Oz wants pharmacy benefits managers (PBMs) to end the complicated system of drug rebates, or the government will step in to change it.

    Oz also hinted that the Trump administration could issue a rule that is focused on drug price transparency.

    The Supreme Court ruled 6-3 in favor of allowing preventive services to continue under the Affordable Care Act (ACA).

    Last, CMS announced that it will have a 100% Risk Adjustment Data Validation audit for every payment year for every contract.

    Connect with Marc

    Marc on LinkedIn Marc on Twitter THL Podcast Resources THL’s Newsfeed THL’s Blog The Healthcare Labyrinth: A Guide to Navigating Health Plans and Fixing American Health Insurance
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    23 mins