Category: Medicare
Medicaid’s 30-Year Refusal to Stop Funding the Dead
For more than 30 years, Washington has known that Medicaid hemorrhages taxpayer dollars through fraud, waste, and abuse, including payments…
For once, Medicare is trying something that actually saves money
Medicare is the second-largest program in the federal budget, topping $1 trillion last year. In 2023, it accounted for 14% of federal spending — a share projected to reach 18% by 2032. After years of ballooning costs, something is finally being done to slow the growth. A new Medicare pilot program, the Wasteful and Inappropriate Service Reduction model, borrows a successful private-sector tool: prior authorization. And that’s good news.
Medicare Part B premiums now sit at $185 per month — up 28% from five years ago and a staggering 76% since 2015. Last year, 12% of the 61 million Americans enrolled in Part B spent more than a tenth of their annual income on premiums. That burden is unsustainable.
In a system as expensive and fragmented as ours, no one can afford to keep writing blank checks for low-value care.
WISeR, set to launch in Ohio, Texas, Washington, New Jersey, Arizona, and Oklahoma, will require prior approval for a short list of “low-value” services — procedures that research shows are frequently overused, costly, and sometimes harmful.
To some, the idea of Medicare reviewing certain treatments before covering them may sound like red tape. But when done correctly, prior authorization is not a barrier. It is a guardrail — one that protects patients, improves quality, and helps ensure that both tax dollars and premiums are spent appropriately.
The goal of WISeR is simple: Cut unnecessary treatments and shift resources toward more effective, evidence-based care. Critics warn about the possibility of delays or extra paperwork, and those concerns are worth monitoring. But they don’t negate prior authorization’s potential to make U.S. health care safer, more efficient, and more financially stable.
Prior authorization directly targets some of the most persistent problems in health care. Medicare spends billions each year on low-value services. A 2023 study identified just 47 such services that together cost Medicare more than $4 billion annually. Those are taxpayer dollars that could be put to better use.
The private insurance market shows the same pattern: unnecessary imaging, avoidable specialist referrals, and brand-name drugs chosen over generics all contribute to rising premiums. Prior authorization, when used properly, reins in this waste by ensuring coverage lines up with medical necessity and evidence-based best practices. Research from the University of Chicago shows that Medicare’s prior authorization rules for prescription drugs generate net savings even after administrative costs.
Consider one striking example. Medicare Part B covers wound-care products known as skin substitutes. But an Office of Inspector General report found that expenditures on these products skyrocketed over the past two years to more than $10 billion annually. Meanwhile, Medicare Advantage plans — which rely heavily on prior authorization — spent only a fraction of that amount for the same treatments.
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More importantly, prior authorization helps promote evidence-based medicine. It curbs outdated clinical habits and reduces financial incentives to overtreat. Health plans consistently say that prior authorization aligns care with gold-standard clinical guidelines, particularly in areas prone to misuse.
Of course, the system must be designed responsibly. A well-functioning PA process should be transparent, fast, and grounded in strong clinical evidence. Decisions should be made in close coordination with the patient’s treating provider. The appeals process must be straightforward. And both public and private payers should be held accountable for improper denials or harmful delays.
When structured this way, prior authorization is far more efficient than the current “pay-and-chase” model, where Medicare pays first and tries to recover improper payments later.
Prior authorization already works in the private sector. It can work in Medicare.
Public and private payers have an obligation to steward the dollars they spend — whether those dollars come from taxpayers or premium-payers. In a system as expensive and fragmented as ours, no one can afford to keep writing blank checks for low-value care. When implemented wisely, prior authorization keeps coverage aligned with medical necessity, elevates the value of care, and helps deliver better outcomes at a sustainable cost.
Do We Really Need to Slash the Debt?
John Tamny, the free-market economics commentator who edits RealClearMarkets, comes out swinging in The Deficit Delusion: Why Everything Left, Right, and Supply-Side Tells You About the National Debt Is Wrong. Perhaps this isn’t surprising, given the book’s title. It can feel like Tamny is a kid walking through the elementary-school playground, randomly shoving other kids—some of whom are bigger than he—as he attacks one op-ed writer after another for, allegedly, misunderstanding the national debt.
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Fearmongering over Medicare hides the real fix seniors need
Democrats are casting the shutdown showdown as a battle over health care costs, tapping into widespread anxiety over the cost of health care, especially among those enrolled in Medicare. For them, it’s politics. But for millions of American seniors, the worry is real — not just a convenient talking point.
Recent polling shows 58% of Medicare recipients 65 and over are concerned about future health care costs, and half are worried a major health situation could result in either debt or bankruptcy.
If left unchanged, Medicare will be unable to pay full benefits by 2036.
While medical debt is a growing concern among Medicare recipients, the staggering size of the federal debt — largely driven by Medicare spending — is a ticking time bomb Congress can no longer ignore. As one of the largest federal spending programs, Medicare consisted of a jarring $874 billion out of the $6.75 trillion federal budget (about 13 cents of every dollar spent in FY2024).
While Medicare receives some funding from premiums paid by enrollees, the single largest source of revenue comes from the federal government’s general fund. If left unchanged, Medicare will be unable to pay full benefits by 2036.
Medicare Advantage toes the line
Fortunately, policy solutions exist that can help both seniors and taxpayers.
Medicare Advantage merges public financing with private delivery under accountability. The government pays a fixed amount per enrollee to private plans, calibrated by benchmarks and quality measures. Plans that achieve higher star ratings — which were just released for 2026 by the Centers for Medicare and Medicaid Services earlier this month — receive bonus payments. Meanwhile, poor performers lose ground.
This structure introduces incentives for efficiency and quality that are lacking in traditional Medicare. Yet, successive years of cuts to how Medicare Advantage plans are reimbursed have forced several major insurers to announce they’re withdrawing from certain Medicare Advantage markets next year.
Companies like UnitedHealth, Humana, Aetna, as well as regional plans such as UCare (serving Minnesota and parts of Wisconsin) and Blue Cross Blue Shield of Vermont, are withdrawing from select Medicare Advantage counties across the country, citing rising costs. Seniors are using more medical services than expected, driving up claims, while federal reimbursement rates are being cut. Added regulatory and administrative burdens (such as expanded reporting requirements and prior authorization rules) further limit insurers. Together, these pressures make participation unsustainable in some markets.
If unchanged, more insurers will leave Medicare Advantage, and options for seniors will continue to shrink. Meanwhile, Medicare costs are growing much faster than private health care spending.
In 2023, traditional Medicare spent $15,689 per enrollee, more than double the private sector amount. This is a result of the traditional fee-for-service model, which pays providers per treatment instead of per patient, rewarding volume over outcomes, encouraging unnecessary care, and driving up costs.
Conversely, Medicare Advantage’s structure encourages prevention and coordination. To attract enrollees, Medicare Advantage offers supplemental benefits such as vision, dental, hearing, wellness programs, transportation, and over‑the‑counter benefits. Many Medicare Advantage plans now include these extras at little or no additional cost. That flexibility helps tailor benefits to beneficiary needs.
Better treatment, lower costs
When allowed to work, Medicare Advantage delivers higher satisfaction, lower costs, and greater access to coverage than traditional Medicare. One Harvard study found that seniors enrolled in Medicare Advantage had better health outcomes than seniors on traditional Medicare. A National Institutes of Health review of hundreds of studies found that Medicare Advantage provided significantly better quality of care and health outcomes than traditional Medicare by a factor of four to one. Another NIH study found that across 48 studies, Medicare Advantage enrollees received more preventative care and had fewer hospitalizations and emergency visits, shorter stays, and lower total spending.
The financial and quality advantages are clear. One study comparing expected out‑of‑pocket costs in Medicare Advantage versus traditional Medicare found that from 2014 to 2019, projected costs were 18% to 24% lower under Medicare Advantage. For seniors on fixed incomes — that is significant.
RELATED: Democrats deny shutdown is about health care for illegal aliens — then one admits the truth
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Seniors get it. This year, the majority of Medicare beneficiaries are enrolled in Medicare Advantage plans. Over the last two decades, enrollment in Medicare Advantage has skyrocketed. Unsurprisingly, polling shows 93% of Medicare Advantage enrollees were satisfied or very satisfied with their coverage, and 94% would recommend it to their family and friends. The Congressional Budget Office now projects that by 2034, Medicare Advantage could account for nearly two-thirds of all Medicare beneficiaries.
The model for the future
Medicare Advantage provides the model for quality, affordable health care for seniors that aligns with what they prefer. Reducing regulatory burdens and barriers within the insurance market will provide Medicare Advantage plans greater flexibility and even entice those insurers leaving the Medicare Advantage market to reconsider.
Medicare cannot continue as purely fee‑for‑service without reform — neither for the medical and financial health of Americans, nor for the sake of the federal budget. The current fiscal challenges plaguing the federal budget demand models that can bend the cost curve while improving quality. Medicare Advantage is not a cure-all, but it is among the most promising tools in the toolbox.
