PNHP

Medicaid Campaign Resources

Federal Medicaid cuts are coming to our communities. Every state in the country is going to be under enormous budget pressure in the coming years. How they respond will have a huge impact on the health and financial wellbeing of their residents.

Many of the options facing state lawmakers are downright harmful, including restricting Medicaid eligibility; cutting “optional” services like pharmacy and dentistry; or reducing funding for other state programs like education.

But the large number of states that contract with corporate health insurers to administer Medicaid have another option: Cancel their managed care contracts, recoup tens or hundreds of billions of dollars annually, and protect residents from the worst impacts of federal Medicaid cuts.

State Legislation

To see how deprivatization would impact Medicaid spending in your state, click HERE.

Campaign Materials

Dr. Ed Weisbart makes the case for deprivatization

PNHP national board secretary (and report co-author) Dr. Ed Weisbart dove into the details of “Removing the Middlemen from Medicaid: A Blueprint for Better Care and Lower Costs” during an Oct. 2025 People’s Action webinar.

Medical student leaders at PNHP’s Annual Meeting

SNaHP leaders Amelia Smith (MS, M2, report co-author) and Gita Lakshminarayanan (M3/PhD candidate) presented an overview of “Removing the Middlemen from Medicaid: A Blueprint for Better Care and Lower Costs” at PNHP’s 2025 Annual Meeting in Washington, D.C.

2025 Annual Meeting Materials

PNHP’s 2025 Annual Meeting in Washington, D.C. drew physicians, students, and health justice activists from across the country for a weekend of organizing, strategizing, and setting our agenda for the year ahead.

Please see below to access a selection of archival recordings, slideshows, and handouts from the meeting. To view photos from the meeting, visit our Flickr page.

During the conference, we encouraged attendees to post to social media using the hashtag #PNHP2025. Be sure to follow PNHP on Instagram, Bluesky, TikTok, and Facebook for the latest on the Medicare for All movement.

Looking for materials from the Students for a National Health Program (SNaHP) Summit? Click HERE to access slideshows, photos, handouts, and more!

Health Policy Update

PNHP past president Adam Gaffney, MD, MPH presented the latest data on the U.S. health crisis, the rising tide of authoritarianism in our government, and the popular resistance to policies that harm everyday Americans. Download Dr. Gaffney’s slideshow (with a PNHP-branded visual presentation by Dr. Ed Weisbart) HERE.

Removing the Middlemen from Medicaid

SNaHP leaders Amelia Smith (MS, M2, report co-author) and Gita Lakshminarayanan (M3/PhD candidate) presented an overview of PNHP’s new report, “Removing the Middlemen from Medicaid: A Blueprint for Better Care and Lower Costs” (slideshow HERE, report HERE).

Panel Discussion: Building Community, Building Power

Featuring Rob Davidson, MD (Committee to Protect Health Care); Jamila Headley, PhD (Be a Hero); and Hayden Rooke-Ley, JD (American Economic Liberties Project). Moderated by Phil Verhoef, MD, PhD (PNHP immediate past president).

Keynote: Dr. Uché Blackstock

Uché Blackstock, MD delivered a powerful, engaging, and collegial keynote that challenged everybody in the room to stretch our political imaginations and to never lose sight of the human ramifications of the history and statistics we know so well.

No Real Choices for Seniors of Color

PNHP national board member and report co-author Belinda McIntosh, MD presented findings from our recently published report, “No Real Choices: How Medicare Advantage Fails Seniors of Color” (slideshow HERE, report HERE).

Sounding the Alarm on Moral Injury

Anand Habib, MD, MPhil shared the latest findings from PNHP’s moral injury project, including comprehensive survey results and excerpts from our interviews with currently practicing physicians (slideshow HERE).

Workshops

  • First-time attendee welcome, presented by Diljeet Singh, MD, DrPH (slideshow HERE)
  • Using campaign strategy and escalation to win, presented by Richard Bruno, MD, MPH; Lori Clark; and Ken Snyder (slide HERE)
  • Building powerful chapters: one conversation at a time, presented by Akshay Ganesh, M2; Sydney Doe, MD; and Dai Thao (slideshow HERE)
  • Making the ask: membership, basebuilding, and fundraising, presented by Alankrita Olson, MD, MPH; Conny Morrison, MD; and Ananiya Asrat (slideshow HERE)
  • Moral injury and storytelling: building community together, presented by Cassandra Craig, MS, OMS-III; Anand Habib, MD, MPhil; Carol Paris, MD; Toby Terwilliger, MD; Rebecca Delay; Dixon Galvez-Searle; and Anika Thota (one-pager HERE, op-ed videos HERE and HERE, moral injury project webpage HERE)

Social Media Booth

PNHP social media team leaders Zach Pellis, MD and Rachel Fox, M3 interviewed attendees during breaks at the annual meeting, and posted the videos as stories on our Instagram account. Nearly 30 physician, student, and activist members shared why they support single-payer Medicare for All!

Advocacy Day on Capitol Hill

On Monday, Nov. 3, PNHP and SNaHP took to Capitol Hill for our first ever Advocacy Day. We marched, rallied, and held over 100 meetings with congressional office staff despite the U.S. government shutdown.

Our main asks for the day were for elected officials to oppose the WISeR model that would introduce prior authorizations into traditional Medicare (handout HERE) and to address the many ways that Medicare “Advantage” worsens racial health inequities (handout HERE).

Advocacy Day Media Coverage

NBC4 Washington aired a segment featuring PNHP president Dr. Diljeet Singh and PNHP immediate past president Dr. Phil Verhoef.

WUSA9 (CBS Washington) aired a segment featuring SNaHP leader Rachel Fox.

Students for a National Health Program (SNaHP) Summit

More than 100 medical and health professional students came from across the country to Washington, D.C. for the annual SNaHP Summit on Saturday, Nov. 1 (agenda HERE, newsletter recap HERE).

These students built the community—and power—we’ll need to win Medicare for All!

Welcome to D.C.

After an opening visit from some (ahem) national leaders, students were welcomed to the SNaHP Summit (slideshow HERE) and to Washington, D.C. (slideshow HERE).

Regional Breakouts

The record number of students attending the SNaHP Summit broke out into regional groups representing the West, Midwest, Northeast, and South. They discussed SNaHP priorities and campaigns for the coming year.

Breakout Sessions

  • Organizing through mutual aid, presented by Evan Hawthorn, OMS-III and Walker Foley, M2 (slideshow HERE)
  • Building political movements, presented by Kevin Hu, M3 and Helen Bassett, M4 (slideshow HERE)
  • Building powerful chapters: one person at a time, presented by Akshay Ganesh, M2 and Dai Thao (slideshow HERE)
  • Turning up the heat: escalating to direct action, presented by A. Taylor Walker, MD, MPH and Andy Hyatt, MD (worksheets HERE)

Poster Presentation

Dozens of students presented a total of 23 posters on a range of topics—from vaccination to transportation to advocacy—during the SNaHP Summit and PNHP Annual Meeting (posters HERE).

Lunch Speaker: Doctors Agains Genocide

Emman Hussny, MD and Dania Khallad, LMHC of Doctors Against Genocide provided an overview of their work, which highlights physicians’ duty to diagnose, treat, and prevent genocide (slideshow HERE).

No Real Choices

How Medicare Advantage Fails Seniors of Color

Physicians for a National Health Program, October 15, 2025

Table of Contents

To view a printable PDF version of this report, click HERE.

To view one-page printable handouts, click HERE (one-sided) and HERE (double-sided).

Executive Summary

The Medicare Advantage (“MA”) program, through which health insurance corporations contract with the federal government to deliver Medicare benefits, offers enrollees few upfront costs, an outof-pocket maximum, extra benefits, and a simple enrollment process. However, these advertised benefits show themselves to be hollow when carefully studied, revealing a program that compromises access, equity, and quality of care. Evidence from an exhaustive literature review and new research reveals that MA enrollees often encounter steep barriers to the physicians and hospitals people with complex conditions need for medically necessary care.

Contrary to claims from the insurance industry that MA is a solution to inequity, racial and ethnic minorities enrolled in MA continue to face many of the longstanding disparities that are common in American healthcare. The financial model of MA does little to mitigate existing inequities – and often exacerbates them by disproportionately offering communities of color inferior insurance products. At the same time, MA places a heavier burden on federal spending than Traditional Medicare (TM), which raises doubts about whether the program truly provides worthwhile returns for the people it is meant to serve. 1.2

In this report, we demonstrate that communities of color that have been historically deprived of wealth accumulation and disposable income are unable to afford the premiums for supplemental insurance (e.g., “Medigap” and a separate Part D pharmacy benefit) that most people in TM depend upon to mitigate the unlimited coinsurance and hospital deductibles in TM. Like TM, MA also includes coinsurance and deductibles; unlike TM, MA includes a statutory maximum on out-of-pocket expenses, a pharmacy benefit, and a very low monthly premium, all without patients needing to pay for any supplemental insurance policies. In fact, MA plans that include these attractive features are widely available for less than $20 per month. 3 As the high cost of Medigap makes TM an unaffordable alternative to MA, under-resourced communities frequently have no meaningful choice but to enroll in more restrictive MA plans, ensnaring them in a bind we label the “Gap Trap.”

In collaboration with Johns Hopkins University researchers, we conducted a cross- sectional analysis of more than 2,400 MA plans to determine whether these plans disproportionately enroll specific racial and ethnic groups, and to evaluate differences in plan quality across them based upon the CMS quality star rating system. Our findings reveal that 23.7% of MA plans disproportionately enroll Asian, Hispanic, and Black Americans, and that these populations tend to be enrolled in the most restrictive and lowest-performing MA plans. In our analysis, plans with the highest concentration of White enrollees averaged 4.3 out of 5 stars while plans with the highest concentrations of Black, Hispanic, and Asian enrollees fell below the 4.0-star threshold required for quality bonuses, averaging 3.86, 3.75, and 3.70 stars, respectively. 4

Introduction

“Everyone deserves affordable high-quality health coverage and care regardless of the individual qualities that make us who we are, like our race, gender, disability, or health status,” says AHIP, 5 the trade association for the health insurance industry. While insurers offering Medicare Advantage (“MA”) have the resources and flexibility to improve health equity, the research reviewed in this report demonstrates that inequities persist without meaningful change. In some circumstances, we found that inequities are significantly worse between groups of people enrolled in MA as compared to those enrolled in TM.

MA is a federally funded program through which health insurers deliver benefits to older adults and people with disabilities. Their HMO and PPO products are an alternative to the government-administered TM program. Insurers in MA make the false promise of lowering costs and improving health outcomes. Our previous reports demonstrated that neither claim is justified. 6,7

In this report we focus on how insurers offering MA fail to improve racial and ethnic health equity, with a particular focus on Black Americans. We center Black Americans in this analysis because they have been the subject of the most extensive equity research, making it possible to document with rigor the ways in which MA fails to mitigate inequities in healthcare.

At the same time, we want to be explicit that these inequities are not unique to Black Americans. Our data includes research on other racial and ethnic groups–including Hispanic, Asian, and Native American populations – but the evidence is far less developed. Available data suggest similar patterns of inequity exist across these groups, and future research must deliberately expand the lens to ensure their experiences are fully captured.

Through our analysis of existing research, we found that MA enrollees from marginalized communities face worse clinical outcomes, higher hospital readmission rates, and limited access to quality care. While the MA program offers insurers the flexibility to reduce cost sharing and ease access to care for vulnerable populations, they do not consistently do so. Rather than benefiting from that f lexibility, the populations most vulnerable to harm are frequently only offered plans with the most restrictive design and lowest quality.

This report presents new research demonstrating that the insurance industry attracts Asian, Hispanic, and Black Americans into the most restrictive and lowest-performing MA plans and too often leaves them without the care they need. The report also explores some of the perverse incentives that are driving this injustice. Regardless of the reasons, any system that traps and harms people – particularly in ways that map onto centuries of racial injustice – cannot be a solution to health inequity.

Many members of Congress have adopted a hands-off approach to MA. Some falsely believe that MA is instrumental to addressing inequity, possibly influenced by decades of industry-funded studies with significant flaws that perpetuate this belief. This report is intended to set the record straight and establish a foundation for long-needed fundamental reforms.

Two Faces of Medicare

President Lyndon Johnson described Medicare as “[…]the seeds of compassion and duty which have today flowered into care for the sick, and serenity for the fearful.” 8 It was designed at a time when half of all older Americans had no health insurance. Insurers would either not cover them or would charge them premiums that were unaffordable. For several decades, Medicare guaranteed that the elderly and people with disabilities had affordable access to high quality healthcare.

With the passage of Medicare, older Americans found themselves in the enviable position of guaranteed access to care. Insurers now lobbied for access to this remunerative population. These efforts led to the passage of the Balanced Budget Act of 1997 through which Congress created Medicare Part C, originally named Medicare + Choice and later reformulated as MA. 9 This was intended as a market-based strategy to establish competition among multiple small insurers. However, the landscape has gradually consolidated into quite the opposite and is now dominated by a handful of large corporations. 10

Insurance corporations have taken over coverage of more than half the people in our cherished public health program. Two very different models of Medicare have emerged: Traditional Medicare and Medicare Advantage.

Traditional Medicare

TM was designed to achieve the mission President Johnson articulated. Nearly all older adults are automatically enrolled into TM when signing up for Social Security. Enrollees have the freedom to receive care from any physician or hospital that accepts Medicare payments, without requiring referrals. Patients in TM face almost no bureaucratic barriers to the care they choose for themselves. For example, TM almost never requires prior authorization for covered services (one prior authorization for every 100 enrollees per year). 11 All enrollees participate in a single unified program with the same set of benefits and the same freedom to choose the care most appropriate for their circumstances.

This structure makes TM fundamentally equitable: every eligible person across the United States is assured of the same benefits.

The program’s finances align directly with the health of the nation, ensuring that the financial returns from long term investments in public health flow back into the Medicare budget. By pooling such a large population, TM maximizes budgetary predictability and distributes the costs of high-expense medical care across millions of enrollees.

The greatest challenge for people in TM is significant personal financial expenditures. Enrollees are responsible for a 20% coinsurance for most outpatient expenses, with no upper limit, and a $1,716 deductible (in 2026) for each benefit period in which they are hospitalized, potentially multiple times per year. 12

To mitigate this, most TM enrollees obtain supplemental coverage, most commonly by personally paying a premium. For example, a 2025 “Plan G” Medigap policy typically limits out-of-pocket costs to $257 annually but averages nearly $2,000 per year in premiums. 13 Other Medigap options are available with varying premiums and out-of-pocket structures. Additionally, enrollees in TM who need prescription drug coverage must purchase a separate Part D plan, 14 adding another premium cost to the overall expense of enrolling in TM that people avoid when opting into MA.

Medicare Advantage

Historically, prepaid health plans held a minor place within Medicare since its enactment in 1965. As part of the 1997 Balanced Budget Act, Medicare Part C was created as a federally funded, commercially administered insurance program called “Medicare Plus Choice” and later reformulated as “Medicare Advantage” under the 2003 Medicare Modernization Act. 15 Since 2004, the share of enrollees in MA has more than quadrupled from 13% to 54% of all Medicare enrollees in 2025. 16,17 Unlike TM, MA is built on prepaid capitations to commercial enterprises whose business model depends on maximizing revenue and minimizing expenses, often at the expense of patient care. 18

MA was originally proposed to cut Medicare costs; this has not been the case. 19 MedPAC estimated that payments to MA in 2025 were $84 billion higher than the same patients would have cost had they been enrolled in TM. 20 Our own 2023 analysis expanded upon the MedPAC findings by also considering the economic impact of county benchmarks, quality bonuses, and induced utilization (setting MA benchmarks based upon the average cost in TM where most people have Medigap). With these additional factors, we estimated the overpayments to MA at $140 billion. 21

Besides financial loss, evidence shows harm to patients, physicians, and hospitals across the MA program coupled with failures to improve care. 22 MA plans consume between 11.1 to 20.5 million clinician hours annually on prior authorizations, 23 time that should be used for patient care. In 2025, nearly 10 million enrollees are in narrow networks excluding more than 75% of local doctors. 24 For some cancers, postoperative death rates are nearly twice as high in MA as TM, mainly due to care delays and limited access to centers of excellence. 25 Copayments, narrow networks, and prior authorizations create systemic barriers to care with dire consequences.

In addition to administrative burdens and narrow networks, investigative reporting reveals troubling practices. According to a 2025 investigation by The Guardian, UnitedHealth Group, the largest healthcare conglomerate in the U.S., secretly paid nursing homes bonuses to cut hospital transfers, saving money and boosting revenues based on their star rating, while risking residents’ health. In several documented cases, patients who needed immediate hospital care did not receive it, and at least one suffered permanent brain damage as a result of delayed transfer. Internal communications show that UnitedHealth supervisors tracked nursing home “budgets” for allowable hospital admissions, effectively rationing care. 26

These problems compound existing racial inequities. One study demonstrated that Black MA enrollees (more so than Hispanic or Asian/Pacific Islander enrollees) face significantly higher rates of preventable hospitalizations compared to White enrollees, with even worse disparities in lower-rated plans. This study suggests that providing more consistent access to higher-rated plans could help reduce these disparities. 27

In summary, while TM continues to embody President Johnson’s original promise of equitable, universal access, MA is eroding those basic guarantees.

Chart 1: Utilization of healthcare services in MA 28

The Equity Illusion

Diversity is not Equity

Recent history outside of health care shows that higher representation of minority populations does not equate to equity. In 2006, subprime mortgages were issued to 26% of White homebuyers, 47% of Hispanic homebuyers, and 53% of Black homebuyers. 29 In 2022, 4% of White Americans received payday loans, compared to 6% of Hispanic Americans and 12% of Black Americans. 30 Subprime mortgages and payday loans were disproportionately marketed to communities of color despite banks knowing this would make them more vulnerable to debt traps and foreclosures. These financial products were revealed as predatory practices and are not solutions to racial inequity. In these contexts, greater diversity does not necessarily mean greater equity.

The failure of diversity as proof of equity can also be documented in healthcare. Lower-income enrollees from minority racial and ethnic backgrounds are significantly more likely to select MA plans. As we demonstrate below, this is not because these plans offer superior care, but because financial limitations leave people in lower income groups with no choice.

One study notes that between 2009 and 2018, MA enrollment among Black individuals grew by 66% (from 23% to 38%), while Hispanic enrollment rose by 43% (from 33% to 48%). But growth of enrollment was steepest among enrollees in the most disadvantaged neighborhoods, where enrollment increased from 25% to 40% – a 60% relative increase compared to 42% in the least disadvantaged areas. Yet despite this rapid growth, racial and ethnic minority enrollees are disproportionately concentrated in lower-quality plans and are offered fewer high-quality plan options. For example, Hispanic enrollees are significantly more likely to enroll in zero-premium plans (53.3%), which tend to offer narrower networks, higher cost-sharing for out-of-network care, and fewer high-quality provider options. 31 These patterns emphasize that financially vulnerable beneficiaries often choose MA because cost barriers leave them with no real choice – forcing them to trade affordability for low quality care. 32

Although MA has a higher percentage of diverse populations (29%) compared to TM (19%), with 54% of all Medicare enrollees from diverse backgrounds choosing MA in 2021 33 versus 46% of MA enrollment overall that year, 34 this does not mean that the program is fulfilling its promise of improving equity. Insurers often cite these enrollment numbers as proof they are closing health equity gaps, but closer inspection shows the evidence does not support this claim.

Insurers use strategic tools to attract people of color into MA plans, 35,36 particularly among lower-income beneficiaries. These individuals typically have complex health needs which are expected to generate billions in profit for health insurers in the coming years, despite being a group that typically racks up expensive health care bills.” 37 Insurers argue that increased funding to MA plans is justified, however, that funding is inconsistently applied towards meaningful improvements in plan quality. 38,39

In fact, subjective experiences and healthcare measures are often worse for minority MA dual beneficiaries, suggesting that the plans are of lower quality. 40 According to a 2021 report from the CMS Office of Minority Health: “With just one exception, racial and ethnic minority beneficiaries reported experiences with care that were either worse than or similar to the experiences reported by White beneficiaries.” The disparities are even more pronounced in clinical care measures. The same study reported that API enrollees fared worse than White enrollees on six measures, Black enrollees had poorer results on 14 clinical measures, and Hispanic enrollees had worse outcomes on 16 measures. Black, Asian, and American Indian enrollees in MA had significantly worse clinical outcomes than White enrollees. 41 These findings emphasize that inequities in MA are not confined to one group – they span across racial and ethnic minority populations.

Some of the research on Hispanic enrollees in MA plans is unclear. Hispanic enrollees face worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic-White disparities in delaying care due to cost and reporting problems paying medical bills appeared narrower in MA relative to TM. 42 Another study comparing Hispanic versus non-Hispanic White enrollees suggested the gaps in quality of care were smaller in MA than in TM for all outcomes. 43 It is worth acknowledging that while some research suggests that TM fares worse for some minority demographics, there is still a significant observable difference in quality and accessibility of care compared between people of color and White enrollees within TM. 44

Chart 2: Characteristics of MA plans by race (2016 data) 45

The inequities run deeper when we examine quality outcomes. Historically, Black enrollees in Medicare managed care plans have consistently received lower-quality care than their White counterparts. A 2002 study of HEDIS performance data found that Black enrollees had significantly lower rates of preventive screenings, follow-up care, and essential treatments, even after adjusting for confounders. 46 Although an older study, its conclusions establish a trend that has continued for decades. A 2024 study demonstrated that nearly one in ten MA enrollees report experiencing unfair treatment in healthcare settings, with the highest prevalence among those with disabilities, lower incomes, and racial and ethnic minorities. 47

Additional research shows that, on a national level, Black MA enrollees continue to experience significant disparities in managing blood pressure, cholesterol, and glucose, with little to no improvement over time. 48 Similarly, MA plans serving socioeconomically disadvantaged populations tend to perform worse on key health measures (blood pressure, diabetes, and cholesterol control) compared to those serving wealthier populations. 49

These disparities are also evident in hospital outcomes. Black MA enrollees experience higher rates of readmission compared to their White peers. In New York State, Black MA enrollees were 64% more likely than White enrollees to be readmitted to a hospital within 30 days after surgery, compared to a 33% disparity among TM enrollees. 50 These findings indicate that risk-reduction strategies adopted by MA plans have failed to equitably reduce readmissions, potentially stemming from inadequate post-discharge care coordination and network restrictions that disproportionately affect Black patients.

Chart 3: A review of MA outcomes data in minority enrollees vs White enrollees 51

Compounding these inequities are barriers created by prior authorization (PA). While insurers argue that PA ensures appropriate use of resources, abundant evidence shows that prior authorization frequently delays or denies necessary care, especially costly care for older adults with chronic or complex conditions.

A 2022 Office of Inspector General (OIG) report found that 13% of prior authorization denials 52 in MA would have been approved under TM, demonstrating that insurers routinely deny MA patients care they would otherwise have received in the public program. The same report found that 18% of payment denials for services already provided also would have been covered under TM. The scope of this problem has drawn congressional scrutiny. A 2024 KFF analysis revealed that 99% of MA enrollees 53 are in plans requiring prior authorization for at least one service. The most frequently affected areas include high-value services such as advanced imaging, durable medical equipment, and post-acute care, with some plans even requiring PA for chemotherapy and skilled nursing facility admissions – critical services where delays can have life-altering consequences.

This limitation on access to care is further compounded by the shortage of clinicians, projected to grow to 86,000 physicians by 2036. 55 At the same time, more than 77.2 million people live in primary-care Health Professional Shortage Areas (HPSAs). 56 These shortages are not evenly distributed; majority-Black communities are more likely to face inadequate primary-care supply. 57

One of the primary causes of this shortage is physician burnout, which results in early retirements and reductions in clinical hours. Nearly one in three physicians have expressed an intention to leave practice within two years, citing burnout as a primary reason. 58 Burnout is driven by excessive administrative burden, and prior authorization consistently ranks among the top contributors. In 2024, 89% of physicians reported prior authorization increases burnout. 59

Because nearly all MA enrollees are in plans that rely on prior authorization, increased diversity in MA could magnify these pressures among people of color. Unlike TM, where prior authorization is uncommon, insurers’ heavy reliance on utilization management tools in MA increases clinician workload and frustration, accelerating burnout and workforce attrition. This leads to fewer practicing physicians and longer patient wait time. These negative effects are most severe in minority communities, where enrollment in MA is higher and where many live in areas already known to be shortage zones.

The Quality Bonus Program (QBP) is the Centers for Medicare and Medicaid Services’ (CMS) system of awarding bonus payments to MA plans. 60 On the surface, the QBP seems a straightforward way to measure and reward higher quality MA plan performance.

Even as imperfect as they are, the star ratings are clinically meaningful for patients. They measure plan performance on cancer screening, hospital readmissions, emergency room aftercare, diabetes, hypertension, heart disease, osteoporosis, and chronic pain. They include measurements of customer service, care coordination, member turnover, timeliness of PA appeals, etc.

The star ratings also have significant financial implications for MA plans. The MA payment structure includes a “rebate” that allows plans to retain a variable portion of the difference between the CMS cost benchmark and the plan’s submitted bid to CMS. As star ratings increase, plans can keep a larger share, increasing from 50% up to 75% 61 of the bid-benchmark gap. CMS also provides an additional bonus of 5% of capitated payments to MA plans that achieve at least 4.0 stars. This bonus can increase to 10%, known as a “double bonus” 62 for insurers operating in certain large metropolitan areas within counties characterized by both below-average per-person TM spending and high MA adoption. However, restricting double-bonus eligibility to counties with below-average TM spending tends to funnel resources into healthier, wealthier communities. Since Black enrollees are 35% less likely than White enrollees to reside in counties that qualify, 63 these double bonuses disproportionately benefit communities with larger White populations, thereby exacerbating racial inequities.

Plans often use these extra funds to enhance supplemental benefits or reduce out-of-pocket costs – desirable enhancements especially in underserved areas. The current system thus shifts resources away from the neediest communities, with potential negative impacts on equity. The availability of particular MA plans varies geographically. In addition, the CMS quality bonus payment system more frequently benefits Whiter, wealthier communities as compared to poorer communities and communities of color.

Studies indicate that Black, Asian, and Hispanic enrollees in MA are less likely to be enrolled in higher-quality plans and more likely to be enrolled in low-quality plans as compared to White enrollees. 53% of Black, 42.2% of Asian, and 59.9% of Hispanic enrollees were in plans rated 4 stars or above, compared with 69.8% of White enrollees. 65 Conversely, 34.9% of Black, 36.8% of Asian, and 27.7% of Hispanic enrollees were in plans rated 3.5 stars or below, compared with just 22.4% of White enrollees. 66 This is significant because enrollment in lower-quality plans means that minority enrollees are systematically denied the higher standards of care and benefits that White enrollees more often receive.

A 2022 CMS report found that racial and ethnic disparities persist across numerous clinical quality measures. 67 Further research demonstrates inequities in quality of care between enrollees of color versus White enrollees regarding behavioral health care, 68 emergency department use, 69 outcomes in preventive care, hospitalizations, mental health treatment, and access to highly rated plans. 70

These disparities in MA plan characteristics do not result from poor consumer choices but instead reflect geographic differences in plan availability. Counties with higher unmet social needs were found to have a lower likelihood to access of high-quality plans, with vulnerable markets averaging 1.1 fewer 4-star or higher plans than less disadvantaged areas. 71 While Black, Hispanic, and Asian enrollees have lower enrollment in higher quality plans than White enrollees, these differences shrink dramatically once county- level plan offerings are taken into account. For example, the gap for Black enrollees decreases from −9.1 to −0.5 percentage points, for Asian/Pacific Islander enrollees from −15.9 to −5.0, and for Hispanic enrollees from −12.7 to 0.6.

When focusing specifically on counties that offer a 5-star plan, Black enrollees are more likely than White enrollees to choose the higher-rated option by 3.2 percentage points. 72 Therefore, when offered higher quality plans, Black enrollees are more likely to choose plans with higher ratings. Rather than choosing poorly, Black MA enrollees are limited to the inferior choices that are available in their communities.

MA plans operate under a managed care model that limits enrollees to a specific network of providers, often excluding high-quality hospitals and specialists. This is particularly stark in MA plans with closed-network HMO models, but even when MA plans built as PPO models allow for non-network care, the higher coinsurance requirements still place an unequal burden. 73,74

There is growing evidence that racial concordance among patients of color and their physicians results in better health outcomes such as higher life expectancy, increased willingness to receive preventative care, and lower infant mortality rates. However, Black and Hispanic physicians are underrepresented in MA networks. One study analyzing racial concordance found that 20% of Black and Hispanic enrollees had no available same-race physicians included in their MA network. Additionally, only 43.2% of Black physicians and 44% of Hispanic physicians were included in a given enrollee’s county as compared to 51.1% of White physicians. 75 This discrepancy limits access to culturally competent care, reinforcing barriers to preventive services and widening existing disparities.

Cost of Care and the “Gap Trap”

TM has no upper cap on out-of-pocket expenses, making supplemental coverage a crucial safeguard against financial risk. For those without Medicaid or retiree benefits from a union or former employer, Medigap coverage can be very expensive, especially for communities of color who face longstanding barriers to wealth accumulation. Consequently, Black enrollees in both MA and TM face greater cost-related obstacles to care compared to White enrollees. 76

59% of Black and 67% of Hispanic Medicare-eligible adults are enrolled in an MA plan. 77 This pattern is driven largely by financial necessity. 40% of Black and Hispanic Medicare enrollees are near-poor, with incomes between 101% and 250% of the federal poverty level (FPL). These individuals may not be eligible for Medicaid supplemental insurance 78,79,80 and often are unable to afford necessary care. MA’s cap on out-of- pocket expenses and additional benefits leaves them with no affordable alternative. 81 This pattern, which we call the “Gap Trap,” forces low-income older adults into MA.

While MA helps enrollees avoid the high cost of Medigap premiums, it provides weaker protection against actual healthcare expenses – posing the greatest risk for those in fair or poor health, who most need comprehensive coverage. In TM, there is almost no difference between Black and White enrollees (25% and 27%) as to whether they are forced to delay or skip care due to cost. However, for comparably unwell people in MA, 35% of White and 50% of Black enrollees report cost-related problems accessing care. 82

If MA plans were designed to promote equity, they would reduce cost-sharing and out-of-pocket limits for low-income enrollees. The high cost of Medigap coverage leaves many financially limited to MA plans, undermining true equitable access by limiting enrollees’ ability to choose the coverage that best meets their needs. 83

Hospital closures are among the most severe and consequential results of MA insurers’ denied and discounted payments to providers, and they disproportionately affect communities of color. 84 TM provides stability by reliably and quickly reimbursing a predictable amount at an established fee schedule, combined with rural protections like Critical Access, 85 Sole Community, 86 and Medicare Bad Debt Reimbursement. 87 These safeguards do not carry over to MA. In contrast, MA insurers pay hospitals at rates as much as 15 percent below TM level while also imposing higher rates of denials, extensive prior authorization requirements, and leaving them without access to the rural protections described above. 88

As enrollment in MA grows, these differences have a profound effect on hospital finances. Between 2018 and 2023, the share of rural hospitals with more MA inpatient days than TM nearly tripled, and more than half of rural counties now have MA penetration exceeding 50%. 89 In these markets, each additional percentage point of MA enrollment increases hospitals’ exposure to lower reimbursement, delayed or denied claims, and uncompensated patient cost-sharing. The Center for Healthcare Quality and Payment Reform estimates that more than 700 rural hospitals are now at risk of closure, with underpayment by private plans, including MA, as the leading driver. In their words, “The primary reason hundreds of rural hospitals are at risk of closing is that private insurance plans are paying them less than what it costs to deliver services to patients…Congress should require that MA plans pay small rural hospitals adequately.” 90

The pattern may also apply to urban communities. Because Black and Hispanic individuals are more likely to enroll in MA, urban hospitals that serve predominantly minority populations also obtain a larger portion of their revenue from MA plans. Like rural hospitals, they lose the stabilizing effect of predictable Medicare reimbursement and supplemental payments that are essential for their survival. This situation can be especially challenging for many safety-net and teaching hospitals, which are already under financial strain. Research shows that safety-net hospitals care for a disproportionate number of low-income and minority patients, provide higher levels of uncompensated care, and consistently operate on thinner margins than non-safety-net institutions. 93

MA’s reimbursement structure does not simply impose administrative burdens on hospitals; it undermines the financial stability of the institutions most critical to underserved populations. When hospitals close, the inequities are profound and enduring. Entire communities lose immediate access to care, travel distances and wait times increase, and health outcomes worsen. Because closures cluster in rural and urban communities of color, MA contributes to racial and geographic inequity in the most fundamental measure of access: whether a hospital stays open at all.

Misleading Marketing of MA

Deceptive Sales Tactics

A 2023 Senate Finance Committee report 94 documented how seniors are misled by sales tactics they described as “deceptive” or “overwhelming.” For example, some agents assured seniors that their doctors were covered under new plans, only for them to later discover their physicians were out-of-network. Others received mailers designed to mimic official government correspondence, when in fact they were advertisements. Celebrity-driven television ads claimed seniors were missing out on benefits or even higher Social Security payments, pushing them toward call centers run by plan agents or brokers. Most troubling, there were reports of vulnerable seniors and people with disabilities having their plans switched without consent.

Paper Benefits that Fail to Deliver

Deceptive marketing and a lack of affordable alternatives drive enrollment in MA. In 2022, insurers spent an estimated $6 billion 95 on advertising campaigns – many of them misleading 96 – aimed at attracting seniors with promises of extra benefits.

MA plans frequently advertise supplemental benefits not covered under TM, such as dental, vision, hearing aids, fitness programs, or pharmacy discounts, but these benefits are often limited, fragmented, or difficult to access. They also come with hidden costs like narrow provider networks and restrictive prior authorization requirements. Without robust networks or transparent coverage details, these so-called “extras” can fail to deliver meaningful improvements in health and may not be functionally available at all. For example, one analysis of some of the more popular supplementary benefits identified that MA enrollees typically save an average of $20 on eyeglasses, $22 on durable medical equipment like hearing aids, and $23 per dental visit compared to those in TM. 97 These are national averages; by definition, some plans are more generous, others more restrictive. It is difficult for consumers to access enough information to inform personal decisions on this level of detail.

For example, dental benefits in MA often limit coverage to a network so limited that patients must pay entirely out of pocket unless they are able to travel prohibitively long distances. Such dental plans often limit coverage to an annual cap as low as $1,000 (well below the cost of more than the most basic dental procedures), 98 require a 50% coinsurance for anything beyond preventive care, and include exclusions or waiting periods for certain procedures. 99,100 Because wealthier enrollees are more able to pay out-of-pocket when such benefits fall short, MA’s “paper benefits” widen health disparities.

Insurers can determine which supplemental benefits to include when designing an MA plan and more consistently include features that would attract healthier members (e.g., fitness club memberships). They are less likely to offer benefits which support people with serious health concerns, such as support for caregivers, in-home services, and bathroom safety devices. 101

Chart 4: Breakdown of Optional Benefits in MA Plans 102

Confounded Industry Research

Much of the research promoted by the insurance industry to present MA as an equity solution is deeply flawed. The industry’s trade association, AHIP, cites studies purporting improved outcomes for MA enrollees, yet these studies often rely on diagnostic coding data that has been artificially inf lated through “upcoding.” To boost capitation payments, MA insurers use aggressive strategies to capture more diagnostic codes than are typically recorded in TM. This practice not only generates billions in unjustified revenue for insurers, draining $40 billion 103 in taxpayer funds in a single year, but also skews risk profiles, making enrollees seem sicker on paper then they are. Research comparing outcomes for genuinely sicker populations against genuinely healthier, upcoded populations can lead to misleading conclusions.

A common tool used in such analyses is the Charlson Comorbidity Index (CCI), which predicts mortality risk based on diagnostic codes. While widely used in health research, the CCI and similar tools are particularly vulnerable to distortion 104 in the MA context, where diagnostic inflation is rampant. Because MA plans systematically capture more diagnoses than are recorded in TM, the CCI makes MA enrollees look far sicker than they are. This allows insurers to claim that their plans are managing more complex populations and producing better outcomes, when in fact the apparent gains are statistical artifacts. For example, an MA enrollee who receives more diagnostic codes during a health risk assessment will have a higher CCI score than a similar TM enrollee, even if their true health status is no different. The result is that studies using unadjusted diagnostic coding data systematically overstate the effectiveness of MA.

One example of confounded data generating uninterpretable conclusions was recognized in a study commissioned by industry’s advocacy group Better Medicare Alliance (a 501(c)(4) advocacy coalition that promotes MA), which acknowledges that “…differences between MA and FFS and submission of data may introduce limitations. MA plans and FFS providers may differ in diagnostic coding patterns, which may hinder the accuracy of matching MA and FFS beneficiaries on clinical profiles. MA plans have an incentive to thoroughly identify beneficiary diagnoses, while FFS providers may not. Utilization metrics were chosen to mitigate the impact of these differences; however, differences in coding patterns could affect the matching procedure itself.” 105

A study by Kronick and Welch illustrates the magnitude of this problem: between 2004 and 2013, average MA risk scores rose sharply from 90% to 109% of FFS risk scores, 106 driven not by increases in morbidity but by inflated coding. Other peer-reviewed research documents risk score inflation ranging from 8% to over 20% 107 annually, with some insurers boosting scores by an additional 12.8% 108 through manipulated health risk assessments. Higher recorded illness levels make it appear that these plans are managing sicker populations more effectively, even when no real health gains have occurred.

CMS is continually trying to address this and is now on version 28 of their risk adjustment factor (“RAF”) scoring methodology, with further iterations likely. 109 Regardless of any ultimate improvements in accuracy and predictability, decades of flawed data will remain a rich source for distorted and misleading research.

This confounds research that relies on unadjusted claims data and enables MA proponents to present inflated performance metrics as genuine improvements. In short, what appears to be higher quality care is often just the result of diagnostic inflation.

The consequences of all of this are stark: disenrollment rates spike among MA enrollees in their final year of life, when their need for care is greatest. Enrollees in their final year of life are more than twice as likely to leave MA plans and return to TM: 4.5–4.6% of those in their last year of life disenrolled, compared to just 1.7–2.0% of other enrollees. 110

The very populations most drawn to these plans have the fewest real resources for essential care, reinforcing inequities rather than closing them.

PNHP & Johns Hopkins Research

Quantitative Research

These inequities set the stage for our collaboration with researchers at Johns Hopkins University, where we sought to examine whether the structure of MA itself reinforces racial and ethnic disparities. Using 2023 Medicare Beneficiary Summary Files linked to MA/Part D Contract and Enrollment Data, as well as 2023 County Health Rankings, the Hopkins researchers conducted a cross-sectional study of 2,489 MA plans across all 50 states and the District of Columbia. 111 Analyses were carried out at the plan–race level with race-stratified linear probability models, allowing an assessment of how plan characteristics interact with county-level demographics such as racial composition, segregation, income, and provider supply.

The researchers identified plans as outliers when they enrolled a racial or ethnic group at least 10 percentage points above the local average, ranked among the top 5% for that group, and showed this pattern in more than one county. The industry refers to these outlier plans as “affinity plans”. By these criteria, the Hopkins researchers identified 623 affinity plans (270 Black, 126 Hispanic, 78 Asian, and 149 White). Together, nearly one in four MA plans (23.7%) met the affinity criteria for at least one racial or ethnic group. 112

The findings revealed striking disparities. Plans with highly concentrated Black enrollees had significantly lower star ratings than non-affinity plans serving Black enrollees (mean 3.86 vs. 4.04) and operated across more counties (mean 224.7 vs. 64.0). Hispanic- and Asian-concentrated plans followed a similar pattern, with lower quality ratings compared to non-affinity plans. In sharp contrast, White-concentrated plans had higher star ratings (mean 4.31 vs. 4.01). 113

Taken together, the plans disproportionately serving Black, Hispanic, and Asian beneficiaries tend to be of lower quality and more restrictive, while plans disproportionately serving White beneficiaries tend to be of higher quality. Far from advancing equity, these patterns perpetuate disparities in access and outcomes.

The table below summarizes one of the major findings of the new research from Johns Hopkins.

Table 1: Racial and Ethnic Sorting in Medicare Advantage Plan Enrollment 114

This methodology focused on the most pronounced cases of racial enrollment imbalances, likely just the tip of the iceberg, and may represent patterns that extend more broadly.

Qualitative Analysis

In addition to the quantitative analysis, we partnered with Johns Hopkins University researchers to conduct a qualitative study. The aim was to better understand how race and socioeconomic status shape the experiences of Black Medicare beneficiaries enrolled in MA. Our original design called for two in- person focus groups with Black enrollees aged 65–70: one in Baltimore City and one in Prince George’s County. These sites were chosen intentionally to compare experiences across communities with different levels of wealth. Each group was to include ten participants, balanced by gender, with exclusions for dual eligibles and those with supplemental commercial coverage.

However, recruitment challenges forced us to modify this plan. Ultimately, we were able to conduct one in-person focus group in Prince George’s County, but with only four participants. The Baltimore City focus group could not be completed as designed and was replaced with phone interviews. To ensure sufficient participation, the eligibility criteria were broadened to include beneficiaries in both MA and TM, as well as dual eligibles and those with supplemental insurance. We also expanded the geographic scope to allow Black Medicare beneficiaries from anywhere in Maryland or Washington, D.C. to participate. Four phone interviews have been completed under these expanded criteria.

Despite these limitations, common themes emerged across the Prince George’s County focus group and the phone interviews. Many participants expressed uncertainty about their plan type, as well as confusion and concern that their coverage did not extend to all the services they needed. Our limited f indings emphasize the importance of further qualitative research–particularly studies that explicitly examine how socioeconomic status influences the experiences of people of color in MA plans.

Solutions

If Medicare is to truly serve as a tool for equity, the system must deliver equitable results, not just misleading research and marketing. As the insurance industry’s advocacy organization AHIP states, “Everyone deserves affordable high-quality health coverage and care regardless of the individual qualities that make us who we are, like our race, gender, disability, or health status.” 115 Our findings highlight that urgent reforms are necessary to ensure fair treatment for all enrollees.

Expose the truth about equity. The first step is honesty. Policymakers, providers, and the public must recognize that high enrollment of people of color in MA is not evidence of equity but of a lack of affordable alternatives. Transparency in data, marketing practices, and plan quality is essential to dismantle misleading narratives.

Return to Medicare’s original promise of equitable, universal access to care. Reforms must eliminate geographic variations in plan offerings that enroll people of color into lower-quality plans with narrower networks. Ensure that comparably high quality options are available in every community.

End the “Gap Trap” by introducing a low out-of-pocket maximum in TM. TM must be strengthened by establishing a low limit on out-of-pocket expenses. This would remove the pressure that forces low-income enrollees – disproportionately Black and Hispanic – into MA plans with restrictive networks and inferior care. In 2024, the average MA plan included an out-of-pocket maximum of $4,882 for in-network services and $8,707 for both in-network and outof-network care in PPOs. 116 By one actuarial estimate, a $5,000 maximum in TM would cost CMS $39 billion per year 117 – less than half of MedPAC’s estimate of $84 billion in annual overpayments for MA enrollees in 2025. 118 Other estimates suggest the overpayments in MA may be as high as $140 billion, more than three times as high as the estimate for parity in out-of-pocket payments. 119

Although we would prefer a far lower out-of-pocket maximum in TM, even one set at $5,000 would make TM more competitive with MA while also reducing overall spending in health care. Premiums for Medigap supplemental policies become less expensive as those insurers would not be liable for expenses above the $5,000 maximum, which would help mitigate the Gap Trap.

Match the actuarial value of MA benefits in TM. The actuarial value of benefits offered in MA should be matched in TM. By providing the same level of coverage and supplemental benefits in the public program, we can eliminate the unfair choice that pushes marginalized populations into MA and ensure that all beneficiaries–regardless of race, ethnicity, or income–have the same access to comprehensive, equitable care. The resources required to address both the “Gap Trap” and the TM benefit shortfalls could come from redeploying the overpayments to MA MedPAC estimates annual overpayments for MA enrollees in 2025 amounted to $84 billion. 120 Other estimates suggest the overpayments in MA may be as high as $140 billion. 121 According to a 2023 actuarial analysis, 122 closing the Gap Trap by creating a $5,000 out-of-pocket maximum in TM (a close match to the most common market offerings of MA) would cost CMS roughly $39 billion per year. Adding audiology and optometry benefits to TM at a comparable actuarial value of those programs in MA would cost CMS $21 billion. Even MedPAC’s conservative estimate of $84 billion is more than adequate to begin to level the playing field between TM and MA and end the “Gap Trap.” Explore new models for determining how much MA plans are paid Today’s risk-adjustment model is failing. Under the current MA risk-adjustment model, Hierarchical Condition Categories (HCCs), the more severe diagnoses a plan documents, the higher their risk score, and therefore the higher the federal payment the plan receives. In turn, this creates strong incentives for insurers to upcode. Researchers have found that a variety of alternative approaches, for example incorporating additional data sources with HCCs, were more predictive of true health outcomes (mortality, hospitalizations, drug use), reduced both under-compensation and over-compensation of MA plans, and redistributed payments toward underserved populations, including enrollees with disabilities and more Black enrollees. 123

Approaches like these and others 124,125 merit further exploration to reduce incentives for upcoding, promote equity, ensure that payments are aligned with actual care needs, and establish a more accurate basis for future research.

Learn from models that already deliver equity. A 2009 review found that most studies show that Black Americans with chronic kidney disease on dialysis survive longer than matched White Americans, 126 an outcome thought to be due to universal coverage of dialysis patients by the same insurance, largely TM. 127 A similar pattern has been identified in another large equal-access public program: The Veterans Health Administration. A literature review of racial disparities in the VHA concluded that “Most studies compared mortality between Black and White veterans and found similar or lower mortality for Black veterans… Although there is a lot of research on Black veterans, more research is needed for other racial/ethnic minority groups, including American Indian and Alaska Native, Asian, and Hispanic veterans.” 128

Chart 5: Evidence Map of Risk of Mortality for Racial/Ethnic Minorities vs Whites in the Veterans Health Administration 129

  • Marker size indicates strength of evidence
  • Each marker is a different diagnostic category
  • More details are available at the citation

Conclusions

Despite industry claims to the contrary, racial and ethnic health disparities in the United States are not being reduced by Medicare Advantage. The existing literature and our new research in collaboration with Johns Hopkins University collectively demonstrate that racial minority enrollees in MA suffer from worse clinical outcomes and face barriers accessing best quality care. These disparities stem from factors such as restrictive networks and misaligned financial incentives that fundamentally oppose public health priorities. While MA insurers continue to falsely portray themselves as champions of health equity, their dependence on deceptive data and misleading marketing contradicts this claim. As policymakers consider reforms to Medicare, it is critical to adopt rigorous equity analyses and to endorse policy solutions that prioritize patient well-being.

Limitations & Next Steps

A limitation of our study is that some of the evidence we cited on inequity among racial and ethnic groups within MA was inconsistent. Overall, research suggests that people of color in MA fare worse than White enrollees, but some analyses reported that MA showed no observable difference and occasionally modest advantages for other minority groups compared to White enrollees. Additionally, some cited literature holds that MA had the same, or in some cases, better health outcomes for enrollees of minority groups as compared to TM. This variation highlights the need for a more comprehensive and systematic analysis to definitively understand how MA affects different racial and ethnic communities across a wide range of measures.

While existing evidence strongly suggests that MA worsens inequities, significant literature gaps remain:

  • More research is needed on the long-term health outcomes of minority enrollees in MA compared to those in TM, particularly regarding the effects of restrictive networks and utilization management tools.
  • Little research has examined the long-term financial burden of MA on minority enrollees, including how prior authorization delays, denials, and high out-of-pocket costs shape financial stability.
  • Research has heavily focused on differences between Black and White enrollees within MA plans, but there is limited comparative work on how Black enrollees fare in MA versus TM.
  • Our quantitative research with Johns Hopkins University demonstrated disproportionate enrollment patterns; however, there is little analysis on the reasons behind these patterns. More study is needed.
  • Socioeconomic status as an independent factor influencing experiences in MA versus TM has not been thoroughly examined, especially among people of color.

Addressing these gaps is essential for understanding how Medicare policy can either perpetuate or reduce racial inequities–and for ensuring that future reforms are based on evidence.

Appendix: The Roots of Today’s Health Disparities

This report was produced in direct response to the misleading guidance being circulated by insurers, policymakers, and lobbyists that MA improves care for communities of color. We believe that a comprehensive understanding of racial and ethnic health inequities requires knowing the history of how health care has treated marginalized communities.

Colonial Era to 1865: Health Care as Property Protection: From the founding of this country through the end of the Civil War, health care for Black Americans was never about healing; it was about profit. Enslaved people received only the most rudimentary care necessary to maintain their economic value to White slaveowners. Physicians during this period were often called upon not to save lives and reduce suffering, but to restore labor productivity. Medical experiments on enslaved people were common and brutal, frequently performed without consent or analgesia, and based on the racist belief that Black bodies did not feel pain in the same way as White bodies. 130 This approach to health established the foundation for a system that regarded Black life in economic, rather than humane or moral terms. When slavery ended, the fragile safety net that had been solely designed to safeguard capital, vanished. Freed Black Americans were left with little to no access to healthcare and were predominantly excluded from the burgeoning systems of hospitals and medical institutions. This transition from coerced care to deliberate neglect did not mark the end of racist medical violations; they merely transitioned into different forms.

1900–1930s: Codifying Segregation: The early 20th century marked a turning point in how the American medical system was formalized–and how its foundations were intertwined with discriminatory values. In 1910, the Flexner Report, commissioned by the Carnegie Foundation and authored by Abraham Flexner, purported to standardize medical education in the U.S. and Canada. While reforming medical education by standardizing it around a science-based model, it was founded on racist and sexist biases that caused lasting damage to diversity in the medical field. The report recommended closing many schools that failed to meet the new standards, disproportionately affecting institutions that trained Black Americans and women. In 2020, the Association of American Medical Colleges (AAMC) officially renamed its prestigious Abraham Flexner Award, citing Flexner’s “racist and sexist views, pejorative language, and unsubstantiated statements” as reasons for the change. Of the seven Black medical schools operating at the time, only two– Howard and Meharry–remained open after Flexner’s recommendations. Flexner suggested that Black physicians were inferior to White physicians in ability and intellect. He argued that Black doctors should be trained as “sanitarians” rather than fully-trained physicians or surgeons, and should focus on preventing infectious diseases in the Black community to prevent the spread of diseases to White Americans. 131,132 Ultimately, the Flexner report advanced the agenda of White, male physicians, severely limiting the Black medical workforce.

Health care access was also shaped by geography. Redlining, a policy created in the 1930s by the Home Owners’ Loan Corporation (HOLC), denied loans and investment to neighborhoods deemed “high risk”, which almost always meant Black communities. Redlining didn’t just limit economic mobility; it had profound health consequences, with those in redlined areas having a higher incidence of health issues. 133 Racial inequities were literally built into the physical and institutional landscape of American cities.

1932–1972: The U.S. Government’s Betrayal at Tuskegee: The Tuskegee Study of Untreated Syphilis, conducted by the U.S. Public Health Service, is one of the most glaring examples of medical racism in American history. From 1932-1972, researchers in Macon County, Alabama, enrolled 600 Black men, mostly impoverished sharecroppers – 399 of whom had syphilis – into a study under the false promise of free medical care. What the men were not told was that they would not be treated, even after penicillin became widely available in the 1940s. 134 For four decades the U.S. government allowed these individuals to endure suffering and death, solely for the purpose of studying the natural progression of the disease. In a moment of chilling cruelty, Public Health Service physician Dr. Thomas W. Murrell reflected on the study by writing, “Perhaps here, in conjunction with tuberculosis, will be the end of the negro problem. Disease will accomplish what man cannot.” 135 Tuskegee was not an outlier. It reflected the deep-rooted belief that Black lives were expendable – and that Black suffering was acceptable if it served White institutions. That belief continues to echo in today’s healthcare structures.

The Rise of Segregated and Fragmented Care: As American health infrastructure grew in the 20th century, it did so along explicitly racial lines. Black Americans were systematically excluded from the benefits of New Deal programs such as Social Security, which initially denied coverage to agricultural and domestic workers – jobs held predominantly by Black Americans. 136 When employer-based health insurance took hold in the 1940s and 1950s, it favored unionized and white-collar jobs, locking many Black workers out of coverage entirely.

Even those with insurance were often denied access to White hospitals and clinics. The 1946 Hill-Burton Act, which funded hospital construction across the country, allowed facilities to remain segregated under the guise of “separate but equal.” 137 By 1959, 30% of Southern hospitals refused Black patients entirely and 50% maintained segregated wards. 138 It took the organizing and resistance of thousands – not just legislation – to force compliance with civil rights law.

In 1965, when Medicare and Medicaid were introduced, they were designed to preserve this fragmentation. 139 Medicare Part A, funded through payroll taxes, provided hospital care to all seniors. Although the Civil Rights Act barred federal funding of programs that discriminated by race, Congress did not allocate the proper resources to enforce the act. 140

Medicare Part B (covering outpatient services) was made optional and based on premiums which inherently discriminates against lower-income communities and allows segregation in physician offices to persist.

Medicaid, created under the pretext of “states’ rights,” grants states broad authority to restrict eligibility, disproportionately excluding Black Americans. Even in states with fewer restrictions, Medicaid has been chronically underfunded, weakening its capacity to address inequities.

Instead of closing racial gaps in care, this fragmented system has only deepened them.

The Modern Machinery of Racial Harm: Although MA is promoted as offering increased choice and affordability, it has instead created a two-tiered system of care where individuals with limited resources and complex health conditions often only have access to the lowest- quality MA plans. Currently, MA plans serving a higher proportion of Black enrollees are more likely to receive lower ratings, restrict provider networks, and deny care more frequently.

The consequences of this disparity became painfully clear during the COVID-19 pandemic. Data show that Black Americans experienced a staggering threefold increase in premature years of life lost compared to White Americans. 141 These negative outcomes were not solely due to comorbidities or lifestyle factors – they were the direct result of unequal access to care, employment conditions that increased exposure, and a fragmented, privatized system that failed to respond fairly during the crisis.

Equity Deferred: The promise of equity remains unfulfilled. A 2024 report from the Kaiser Family Foundation documents the ongoing health disparities between Black and White Americans. The data are alarming: life expectancy for Black Americans is more than four years shorter than for Whites (72.8 vs. 77.5 years). Black individuals are more likely to be uninsured (10% vs. 7%) and more likely to go without care because of cost (14% vs. 11%). They are also more likely to report their health as fair or poor (21% vs. 16%) and face significantly higher rates of infant and maternal mortality–more than double and triple, respectively, the rates experience by White Americans. 142 These outcomes are not difficult to anticipate; they are the predictable result of a system that has long regarded Black lives as expendable and Black suffering as acceptable collateral.

Acknowledgements

This report was made possible through generous support from Arnold Ventures, whose funding enabled Physicians for a National Health Program to conduct this important research.

Report authors include Ed Weisbart, MD; Belinda McIntosh, MD; Donald Moore, MD; Stephen Chao, MD; Diane Archer, JD; Pranav Nedumpurath, MD Student; Mark Craig; and Anika Thota.

We also extend our deep gratitude to Faridat Animashaun, JD Student; Jamila Headley, PhD, MSc; Claudia Fegan, MD; Sabrina W. Tyuse, PhD; Tia Taylor Williams, MS, CNS, MPH; Saqib Bhatti, MA, MPP; Steve Kemble, MD, MPH; and Julie Kozminski, MPH for their invaluable guidance, expertise, and thoughtful feedback throughout the development of this report. Their diverse knowledge across public health, public policy, healthcare administration, and related fields significantly strengthened this work.

Endnotes

  1. Physicians for a National Health Program. Taking Advantage: How Corporate Health Insurers Harm America’s Seniors. May 23, 2024.
  2. Center for American Progress. Ending Overpayment in Medicare Advantage: A Proposal To Improve the Value of the Medicare Program. March 19, 2024.
  3. National Council on Aging. What Are the Costs of Medicare Advantage? January 8, 2025.
  4. Andrew Anderson, Ji Mun Li, Darrell J. Gaskin, and Michael K. Meiselbach, Racial and Ethnic Sorting in Medicare Advantage Plan Enrollment (Working paper, Johns Hopkins Bloomberg School of Public Health, 2025), manuscript under review
  5. AHIP. Health Equity.
  6. Physicians for a National Health Program. Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program. October 4, 2023.
  7. Physicians for a National Health Program. Taking Advantage: How Corporate Health Insurers Harm America’s Seniors. May 23, 2024.
  8. Truman Library Institute. “Signing Medicare into Law.”
  9. Medicare Rights Center, Medicare Advantage History: Legislative Milestones. 2023.
  10. Nicole Zhu, Jeannie Fuglesten Biniek, Nolan Sroczynski, and Tricia Neuman, Most Medicare Advantage Markets are Dominated by One or Two Insurers. July 14, 2025.
  11. Biniek, Jeannie Fuglesten, Nolan Sroczynski, Meredith Freed, and Tricia Neuman, Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023. January 28, 2025.
  12. CMS. Medicare and You 2026.
  13. Worstell, Christian, What Is the Average Cost of Medicare Supplement Insurance Plan G? May 30, 2025.
  14. KFF. The Trump Administration is Reducing Enhanced Support for the Part D Stand-Alone Drug Plan Market. July 28, 2025.
  15. Medicare Rights Center, Medicare Advantage History: Legislative Milestones. 2023.
  16. Lindsay Harris, Lori Achman, and Marsha Gold, Medicare Advantage and Medicare Beneficiaries: Monthly Tracking Report for August, 2004. September 7, 2004.
  17. Nancy Ochieng, Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2025: Enrollment Update and Key Trends. July 28, 2025.
  18. Physicians for a National Health Program. Taking Advantage: How Corporate Health Insurers Harm America’s Seniors. May 23, 2024.
  19. Jeannie Fuglesten Biniek, Juliette Cubanski, and Tricia Neuman, Higher and Faster Growing Spending Per Medicare Advantage Enrollee Adds to Medicare’s Solvency and Affordability Challenges. August 17, 2021.
  20. MedPAC. The Medicare Advantage program: Status report. March 2025.
  21. Physicians for a National Health Program. Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program. October 4, 2023.
  22. Ibid
  23. Physicians for a National Health Program. Taking Advantage: How Corporate Health Insurers Harm America’s Seniors. May 23, 2024.
  24. Aditi P. Sen et al. Physician Network Breadth and Plan Quality Ratings in Medicare Advantage. JAMA Health Forum. Published Online: July 30, 2021. 2021;2;(7):e211816. doi:10.1001/jamahealthforum.2021.1816
  25. Mustafa Raoof, Philip H.G. Ituarte, Sidra Haye, Gretchen Jacobson, Kevin M. Sullivan, Oliver Eng, Jae Kim, and Yuman Fong, Medicare Advantage: A Disadvantage for Complex Cancer Surgery Patients. November 10, 2022.
  26. George Joseph, Revealed: UnitedHealth Secretly Paid Nursing Homes to Reduce Hospital Transfers. May 21, 2025.
  27. Sungchul Park, Rachel M. Werner, and Norma B. Coe, Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions. December 2022.
  28. Johnston KJ, Hammond G, Meyers DJ, Joynt Maddox KE, Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures. August 17, 2021.
  29. Algernon Austin, Subprime Mortgages Are Nearly Double for Hispanics and African Americans. June 10, 2008.
  30. Tammy Worth, Kansas Coalition Pushing Payday Loan Reform. November 22, 2022.
  31. David J. Meyers, Vincent Mor, Momotazur Rahman, and Amal N. Trivedi, Growth in Medicare Advantage Greatest Among Black and Hispanic Enrollees. June 2021.
  32. Christopher L. Cai, Sonia Iyengar, Steffie Woolhandler, David U. Himmelstein, Kavya Kannan, and Lisa Simon, Use and Costs of Supplemental Benefits in Medicare Advantage, 2017-2021. January 14, 2025.
  33. AHIP, Increasingly Diverse Segment of Americans Choosing Medicare Advantage. January 10, 2024.
  34. MedPAC, A Data Book: Health Care Spending and the Medicare Program. July 2021.
  35. Alignment Healthcare, Alignment Healthcare Caters to Growing Hispanic Senior Community with Launch of the One, a $0 Premium Medicare Advantage Plan, for 2022. October 6, 2021.
  36. Fierce Healthcare, New UnitedHealthcare “Medicare Explicado” DVD Educates Hispanics About Medicare and Medicaid Benefit Options. November 16, 2011.
  37. Caitlin Owens, Major Shift: Health Insurers Are Suddenly Coveting Sicker Patients. February 14, 2024.
  38. Gangopadhyaya A, Zuckerman S, Rao N, Assessing the Difference in Racial and Ethnic Disparities in Access to and Use of Care Between Traditional Medicare and Medicare Advantage. March 9, 2023.
  39. Paul N. Van de Water, Growth in Medicare Advantage Raises Concerns. January 10, 2025.
  40. Weech-Maldonado R, Elliott MN, Adams JL, Haviland AM, Klein DJ, Hambarsoomian K, Edwards C, Dembosky JW, Gaillot S, Do Racial/Ethnic Disparities in Quality and Patient Experience Within Medicare Plans Generalize Across Measures and Racial/Ethnic Groups? March 11, 2015.
  41. RAND Health Care, Racial, Ethnic, & Gender Disparities in Health Care in Medicare Advantage. April 2021.
  42. Hames AG, Tipirneni R, Switzer GE, Ayanian JZ, Kullgren JT, Racial/Ethnic Disparities in Cost-Related Barriers to Care Among Near-Poor Beneficiaries in Medicare Advantage vs Traditional Medicare. October 23, 2024.
  43. Jeah Jung, Hansoo Ko, Roger Feldman, Caroline S. Carlin, and Ge Song, Gaps in Quality of Care Not Consistent Between Traditional Medicare, Medicare Advantage for Racial and Ethnic Groups. March 2024.
  44. Kenton J. Johnston et al. Association of race and ethnicity and Medicare program type with ambulatory care access and quality measures. JAMA Network. 2021;326;(7):628-636. doi:10.1001/jama.2021.10413
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  47. Megan Mathews, Megan K. Beckett, Steven C. Martino, Julie A. Brown, Nate Orr, Sarah Gaillot, and Marc N. Elliott, Medicare Advantage Enrollees’ Reports of Unfair Treatment During Health Care Encounters. May 29, 2024.
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  52. Office of Inspector General, Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care. April 2022.
  53. Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage in 2024: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization. August 8, 2024.
  54. Boris Vabson, Andrew L. Hicks, and Michael E. Chernew, Medicare Advantage Denies 17 Percent of Initial Claims; Most Denials Are Reversed, But Provider Payouts Dip 7 Percent. June 2025.
  55. AAMC, The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. March 2024.
  56. Bureau of Health Workforce, Health Resources and Services Administration, U.S. Department of Health & Human Services, Second Quarter of Fiscal Year 2025: Designated HPSA Quarterly Summary. 2025.
  57. Darrell J. Gaskin, Gniesha Y. Dinwiddie, Kitty S. Chan, and Rachael R. McCleary, Residential Segregation and the Availability of Primary Care Physicians. April 2012.
  58. Jennifer A. Ligibel, Nicolette Goularte, Jennifer I. Berliner, Steven B. Bird, Chantal M. L. R. Brazeau, Susannah G. Rowe, Miriam T. Stewart, and Mickey T. Trockel, Well-Being Parameters and Intention to Leave Current Institution Among Academic Physicians. December 15, 2023.
  59. American Medical Association, 2024 AMA Prior Authorization Physician Survey. 2024.
  60. Laura Skopec, Robert Berenson. The Medicare Advantage Quality Bonus Program: High cost for uncertain gain. Urban Institute Health Policy Center. June 2023.
  61. Christina Ramsay & Gretchen Jacobson. How the Government Updates Payment Rates for Medicare Advantage Plans. March 4, 2024.
  62. Jeannie Fuglesten Biniek, Anthony Damico, & Tricia Neuman. Medicare Advantage Quality Bonus Payments Will Total at Least $12.7 Billion in 2025. June 12, 2025.
  63. Adam A. Markovitz, John Z. Ayanian, Anupama Warrier, and Andrew M. Ryan, Medicare Advantage Plan Double Bonuses Drive Racial Disparity in Payments, Yield No Quality or Enrollment Improvements. September 2021.
  64. David Meyers et al. Growth in Medicare Advantage greatest among Black and Hispanic enrollees. Health Aff (Millwood). 2021 Jun;40(6):945-950. doi:10.1377/hlthaff.2021.00118.
  65. Ibid
  66. David J. Meyers, Emmanuelle Belanger, Nina Joyce, John McHugh, Momotazur Rahman, and Vincent Mor, Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries. February 25, 2019.
  67. CMS, Disparities in Health Care in Medicare Advantage by Race and Ethnicity. April 2022.
  68. Joshua Breslau, Marc N. Elliott, Amelia M. Haviland, David J. Klein, Jacob W. Dembosky, John L. Adams, Sarah J. Gaillot, Marcela Horvitz-Lennon, and Eric C. Schneider, Racial And Ethnic Differences In The Attainment Of Behavioral Health Quality Measures In Medicare Advantage Plans. October 2018.
  69. Jeah Jung et al. Gaps in quality of care not consistent between Traditional Medicare, Medicare Advantage for racial and ethnic groups. Health Affairs Vol 43 No 3. March 4, 2024. https://doi.org/10.1377/hlthaff.2023.00428
  70. Nancy Ochieng et al. Racial and ethnic health inequities and Medicare. KFF. February 2021.
  71. Hansoo Ko, Ghaida Alsadah, and Gilbert Gimm. Association of Social Vulnerability and Access to Higher Quality Medicare Advantage Plans. June 2025.
  72. Park S, Werner RM, Coe NB. Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans. Health Serv Res. 2023 Apr;58(2):303-313. doi: 10.1111/1475-6773.13977. Epub 2022 Apr 9. PMID: 35342936; PMCID: PMC10012240.
  73. Medicare, Preferred Provider Organizations (PPOs).
  74. Medicare Options 360, Medicare HMO vs PPO.
  75. David J. Meyers, Eunhae Grace Oh, Maricruz Rivera-Hernandez, Momotazur Rahman, and Amal N. Trivedi, Medicare Advantage Networks Include Few Black Or Hispanic Physicians, Making Concordant Care Inaccessible For Many. January 2025.
  76. Gangopadhyaya A, Zuckerman S, Rao N. Assessing the difference in racial and ethnic disparities in access to and use of care between Traditional Medicare and Medicare Advantage. Health Serv Res. 2023 Aug;58(4):914-923. doi: 10.1111/1475-6773.14150. Epub 2023 Mar 25. PMID: 36894493; PMCID: PMC10315374.
  77. Minority Health Institute, Inc., Medicare Advantage’s Role in Improving Health Equity for Seniors of Color. March 2024.
  78. Medicaid, Seniors & Medicare and Medicaid Enrollees.
  79. Medicare, Medicare Savings Programs.
  80. National Council on Aging, Medicare Savings Programs Eligibility and Coverage. May 14, 2025.
  81. Hames, Alexandra G et al. Racial/ethnic disparities in cost-related barriers to care among near-poor beneficiaries in Medicare Advantage vs traditional Medicare. The American Journal of Managed Care vol. 30,10 e297-e304. 1 Oct. 2024, doi:10.37765/ajmc.2024.89622
  82. Jeannie Fuglesten Biniek, Nancy Ochieng, Juliette Cubanski, and Tricia Neuman, Cost-Related Problems Are Less Common Among Beneficiaries in Traditional Medicare Than in Medicare Advantage, Mainly Due to Supplemental Coverage. June 25, 2021.
  83. Nancy Ochieng, Juliette Cubanski, Tricia Neuman, Samantha Artiga, and Anthony Damico, Racial and Ethnic Health Inequities and Medicare. February 16, 2021.
  84. Grace Niewijk, Rising Hospital Closures Disproportionately Affect Disadvantaged Communities. April 26, 2024.
  85. CMS, Information for Critical Access Hospitals. August 2025.
  86. MedPAC, Summary of Medicare’s Special Payment Provisions for Rural Providers and Criteria for Qualification. June 2001.
  87. Jason D. Buxbaum, Ari D. Ne’eman, and Cyrus M. Kosar, Eliminating Bad Debt Reimbursement to Hospitals Serving Traditional Medicare Beneficiaries. August 11, 2025.
  88. Ibid
  89. American Hospital Association, The Growing Impact of Medicare Advantage on Rural Hospitals Across America.
  90. Center for Healthcare Quality and Payment Reform, Rural Hospitals at Risk of Closing. August 2025.
  91. Tarun Ramesh and Emily Gee, Rural Hospital Closures Reduce Access. September 2019.
  92. Tracey T. Stansberry, Patricia N. E. Roberson, and Carole R. Myers, U.S. Rural Hospital Care Quality. November 4, 2023.
  93. Lukas K. Gaffney and Kenneth A. Michelson, Analysis of Hospital Operating Margins. April 3, 2023.
  94. Majority Staff of the U.S. Senate Committee on Finance, Deceptive Marketing Practices Flourish in Medicare Advantage.
  95. Brandon Novick. Medicare Advantage and deceptive marketing. Center for Economic and Policy Research. November 7, 2023.
  96. Majority Staff of the U.S. Senate Committee on Finance, Deceptive Marketing Practices Flourish in Medicare Advantage.
  97. Christopher L Cai et al. Use and costs of supplemental benefits in Medicare Advantage, 2017-2021. JAMA Network Open. Vol 8 No 1. 2025;8;(1):e2454699. doi:10.1001/jamanetworkopen.2024.54699
  98. Dental Depot, Affordable Dental Care: Costs, Insurance & Smart Savings.
  99. Carly Plemons, Do Medicare Advantage Plans Cover Dental Services? July 25, 2024.
  100. Luke Pisarcik, Medicare Advantage Dental Benefit Compare Tool 2024 Insights. November 27, 2023.
  101. Meredith Freed, Jeannie Fuglesten Biniek, Anthony Damico, and Tricia Neuman, Medicare Advantage 2025 Spotlight: A First Look at Plan Premiums and Benefits. November 15, 2024.
  102. Nancy Ochieng et al. KFF. Medicare Advantage in 2025: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization. July 28, 2025.
  103. MedPAC, The Medicare Advantage Program: Status Report, March 2025.
  104. Moiz Bhai and Danny R. Hughes, Estimating Self-Selection in Medicare Advantage. April 2024.
  105. John Barkett, Ruth Tabak, and Caden Riley, Black, Hispanic, and Asian American/Pacific Islander MA Benef iciaries Receive More Primary Care and Less Potentially Avoidable Care Than Similar Beneficiaries in Traditional Medicare. April 2025.
  106. Richard Kronick and W. Pete Welch, Measuring Coding Intensity in the Medicare Advantage Program. 2014.
  107. Vilsa E. Curto, Eran Politzer, Timothy S. Anderson, John Z. Ayanian, Jeffrey Souza, Alan M. Zaslavsky, and Bruce E. Landon, Coding Intensity Variation in Medicare Advantage. January 2025.
  108. Hannah O. James, Beth A. Dana, Momotazur Rahman, Daeho Kim, Amal N. Trivedi, Cyrus M. Kosar, and David J. Meyers, Medicare Advantage Health Risk Assessments Contribute Up To $12 Billion Per Year To Risk- Adjusted Payments. May 2024.
  109. Michael Stearns, Melissa James, and Kimberly Rykaczewski, How CMS-HCC Version 28 Will Impact Risk Adjustment Factor (RAF) Scores. February 27, 2023.
  110. United States Government Accountability Office, Beneficiary Disenrollments to Fee-for-Service in Last Year of Life Increase Medicare Spending. June 2021.
  111. Andrew Anderson, Ji Mun Li, Darrell J. Gaskin, and Michael K. Meiselbach, Racial and Ethnic Sorting in Medicare Advantage Plan Enrollment (Working paper, Johns Hopkins Bloomberg School of Public Health, 2025). Manuscript under review.
  112. Ibid
  113. Ibid
  114. Ibid
  115. AHIP. Health Equity.
  116. Meredith Freed et al. Medicare Advantage in 2024: Enrollment Update and Key Trends. KFF. August 8, 2024.
  117. Physicians for a National Health Program. Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program. October 4, 2023.
  118. MedPAC, Medicare Payment Policy. March 2025.
  119. Physicians for a National Health Program. Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program. October 4, 2023.
  120. MedPAC, Medicare Payment Policy. March 2025.
  121. Physicians for a National Health Program. Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program. October 4, 2023.
  122. Ibid
  123. J. Michael McWilliams et al. Use of patient health survey data for risk adjustment to limit distortionary coding incentives in Medicare. Health Affairs Jan 2025. https://doi.org/10.1377/hlthaff.2023.01351
  124. Ibid
  125. Ibid
  126. Keith Norris, Rajnish Mehrotra, and Allen R. Nissenson, Racial Differences in Mortality and End-Stage Renal Disease. August 1, 2009.
  127. Eunhae Grace Oh, Joan F. Brazier, Emily A. Gadbois, Denise A. Tyler, Laura M. Keohane, David J. Meyers, Momotazur Rahman, Kevin H. Nguyen, and Amal N. Trivedi, Dialysis Facility Participation In Medicare Advantage Networks Was Highest For Large Dialysis Organizations In 2021. March 2025.
  128. Kim Peterson, Johanna Anderson, Erin Boundy, Lauren Ferguson, Ellen McCleery, and Kallie Waldrip, Mortality Disparities in Racial/Ethnic Minority Groups in the Veterans Health Administration: An Evidence Review and Map. March 2018.
  129. Ibid
  130. Kyere E., Enslaved People’s Health Was Ignored from the Country’s Beginning, Laying the Groundwork for Today’s Health Disparities. July 30, 2020.
  131. Wright-Mendoza J., The 1910 Report That Disadvantaged Minority Doctors. May 3, 2019.
  132. Savitt, Todd, Abraham Flexner and the Black Medical Schools. 1992. September 2006.
  133. Ramsay C., Pinnell P., Rees L., Simpson H., Unequal Treatment: The Stark Reality of Healthcare Inequality in the UK. March 24, 2023.
  134. Centers for Disease Control and Prevention, About the Untreated Syphilis Study at Tuskegee. September 4, 2024.
  135. Washington, HA, Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. 2006.
  136. Interlandi, J., Why Doesn’t the United States Have Universal Health Care? The Answer Has Everything to Do With Race. August 14, 2019.
  137. Largent, E. A., Public Health, Racism, and the Lasting Impact of Hospital Segregation. 2018.
  138. P. Preston Reynolds. The Federal Government’s Use of Title VI and Medicare to Racially Integrate Hospitals in the United States, 1963 Through 1967. Am Jnl of Public Health. Vol 87 No 11. Pgs 1850-1858, November 1997.
  139. Hartmann, T., The Hidden History of American Healthcare: Why Sickness Bankrupts You and Makes Others Insanely Rich. September 7, 2021.
  140. U.S. Commission on Civil Rights, Federal Title VI Enforcement to Ensure Nondiscrimination in Federally Assisted Programs. June 1996.
  141. McGough M, Lo J, Amin K, Artiga S, Hill L, and Cox C, Racial Disparities in Premature Deaths During the COVID-19 Pandemic. April 24, 2023.
  142. Artiga S, Hill L, and Presiado M, How Present-Day Health Disparities for Black People Are Linked to Past Policies and Events. February 22, 2024.

Removing the Middlemen from Medicaid

A Blueprint for Better Care and Lower Costs

Physicians for a National Health Program, September 2, 2025

Table of Contents

To view a printable PDF version of this report, click HERE. To view one-page printable handouts, click HERE (full color) and HERE (black & white).

To see how these reforms would impact Medicaid spending in your state, click HERE.

Executive Summary

Background: Medicaid is a joint federal and state health insurance program for people with low incomes. As of April 2025, Medicaid insured 71 million people, including people with disabilities, children and families, pregnant women, the elderly, and working adults without affordable insurance. 1 In addition, Medicaid supports the overall health infrastructure, funding safety-net and rural hospitals, as well as long-term care facilities that serve a large proportion of low-income individuals. In these ways, Medicaid stabilizes healthcare for entire communities.

Issue: The 2025 Budget Reconciliation Act (sometimes identified as the “One Big Beautiful Bill Act”) 2 reduces federal Medicaid funding by $1 trillion over the next decade. A cut of this magnitude puts enormous pressure on states to end optional Medicaid benefits, cut eligibility, reduce provider payments, and/or raise taxes. 

Solution: States that rely on managed care organizations (“MCOs”) to administer their Medicaid programs can substantially offset the federal cuts if they stop MCO contracting and instead directly administer their Medicaid programs. We estimate that if states shifted from MCOs to direct payment of Medicaid providers, they could reduce their Medicaid MCO expenditures by 10 percent to 17 percent. Savings stem from reduced administrative costs and improved care coordination. 

States can operate their Medicaid programs in a manner that encourages primary care practices to manage care. This is called “managed fee for service” (Connecticut Medicaid) or “enhanced Primary Care Case Management” (North Carolina and Oklahoma prior to recent conversion to MCOs). These models include enhanced payment to primary care practices, care coordination programs to improve management of complex and high-risk patients in the community beyond the doctor’s office, and specialized programs for patients with complex care needs. 

Rationale: States spend 4 to 6 percent of their Medicaid budget on internal state agency overhead, plus an additional 13 percent goes to MCOs for their overhead. States that bypass MCOs and pay providers directly can either retain much of what today goes to MCO overhead or re-invest some of those savings back into Medicaid. 3 When a state deprivatizes its Medicaid program, it obviously no longer has to fund MCO overhead. Total state overhead can drop to about 4 to 6 percent 4 or less.

A well-run managed fee for service program can attract primary care physicians back into Medicaid, as demonstrated in Connecticut. 5 This, in turn, can reduce urgent care, ER visits, and preventable hospitalizations, resulting in a net reduction in the cost of medical services. In 2012, Connecticut terminated its MCO contracts and implemented a state-run care coordination program. Physician participation improved by 33% in the first year after the change, and ER visits and hospitalizations declined, 6 with a reduction in total per member Medicaid cost of 15% five years after the conversion to state-run care coordination. 7

Connecticut’s switch from a privatized to a deprivatized program coupled with a new publicly run care coordination program improved quality of care. For example, the change was associated with a 4.7% increase in early cancer detection and 8% higher survival rates compared to New Jersey, which maintained its privately run Medicaid MCO program as Connecticut jettisoned it. 8 In the 13 intervening years, the state of Connecticut has saved more than $4 billion of taxpayer money. 9

In Appendix F (Table 4), we provide a range of projections for the savings a state can anticipate if it moves to a managed fee for service model, varying based on how much care coordination they adopt. The projections are a first-order approximation that does not account for items identified in the notes section to the table that could imply either under-estimation or over-estimation. As one example of under-estimation, these projections are based on FY 2023 state data and do not account for medical inflation in FY 2026.

Table 4 also demonstrates the federal savings opportunity. Total federal MCO Medicaid spending in 2023 was $ 256 billion. We estimate that nationwide deprivatization of Medicaid would have saved the federal government as much as $43 billion in 2023, in addition to the potential for $34 billion savings for individual states, for a total savings of $77 billion combining all state and federal fractions. 

Some states that decided to eliminate managed care from Medicaid have been able to move quickly into managed fee for service. For example, after two years of consideration, 10 the Oklahoma board overseeing Medicaid decided on November 7, 2003 to remove MCOs effective on December 31 2003, and fully transitioned to statewide Primary Care Case Management over the first four months of 2004. 11

In this report we will frequently refer to the state of Connecticut where, in 2012, the state successfully removed MCOs from its Medicaid program. Although it is a small state with about a million Medicaid enrollees, it has actual, recent experience with deprivatization, and so the amount of money saved, administrative costs avoided and access improved there are highly instructive. Connecticut is widely recognized as “the insurance capitol of the world.” 12 If a state with Connecticut’s legacy could remove the insurance industry from its Medicaid program, and reap significant rewards, any state should be able to do the same.

Section 1: Fundamentals of Managed Care

Section 1A: What are “Managed Care Organizations”?

Managed Care Organizations (MCOs) are insurance companies that are pre-paid per person for a defined set of health services for a defined period of time. Payments made to health insurance companies by private-sector buyers (individuals and employers) are typically called “premiums;” payments to health insurance companies by public programs like Medicaid are usually called “capitation payments” (described below).

The concept of managed care first gained widespread recognition in 1973 with the passage of the Health Maintenance Organization Act (“HMO Act”) as an alternative to fee for service on the theory that HMOs could control healthcare costs and improve quality of care. 13 The label “Managed Care Organization” or “MCO” emerged in the 1990s as the distinction between insurers offering HMOs and traditional fee for service insurance companies became blurred. Continuing a process introduced in the early 1980s, 14 federal changes in the 1990s expanded the ability of states to introduce MCOs into their Medicaid programs. 15

HMOs (health plans administered by corporate health insurers) are the prototypical insurance product of managed care organizations. HMO advocates claim that HMOs align the financial interests of an MCO with those of the funding source, driving reduced expenses for the state. By restricting the state’s financial exposure to the contracted capitation rates, capitation theoretically could permit states to stabilize their budgets, control costs and improve population health outcomes. This nearly irresistible insurance industry proposition has been a key driver of the growth of HMOs across the health insurance landscape, including Medicaid.

Rather than investing in improved health outcomes, MCOs’ incentive has been to maximize profits by spending less on care. They delay and deny care inappropriately, regardless of the dire health hazards. The frequent turnover of HMO membership, particularly in Medicaid MCOs, undermines any business case for MCOs to improve people’s long term health and protects MCOs from the consequences of their delaying and denying care. If they can delay care long enough, the patient may leave the MCO’s risk pool.

In some states, capitation also introduces opportunities for gaming the payment system by avoiding or ejecting sicker enrollees to secure a better risk pool and pressuring doctors and patients to up-code diagnoses used for risk adjustment. “Managed Care Organizations” prioritize financial expenses over patient care. In fact, for-profit MCOs have a legal obligation to put their shareholders’ interests ahead of patient care.

Section 1B: Are there alternatives to managed care organizations?

The Omnibus Budget Reconciliation Act of 1981 created “managed fee for service” or what is referred to as “Primary Care Case Management” as an alternative to Medicaid MCOs. 17,18 Medicaid Primary Care Case Management is done by primary care clinics, not insurance companies. The state pays primary care practices a modest monthly fee per patient or enhanced fee for service fees to provide care coordination services that ensure that other providers render appropriate care. In addition, the state pays directly for office visits on a fee for service basis. Managed fee for service allows for true care coordination and does not create the financial incentive to deny health care which capitation creates.

Note: “Care coordination” is described by the Agency for Healthcare Research and Quality as a key strategy with the potential to improve the effectiveness, safety, and efficiency of the health care system. It encompasses care management, teamwork, medication management, assistance with transitions of care, assistance with transportation, monitoring and followup, linkages to community resources, and multiple other activities. 19

In this paper we draw a distinction between these “care coordination” programs and “care management programs.” In a managed fee for service model, state Medicaid programs pay physicians and other health care professionals directly to participate in care coordination programs. In an MCO capitated model, states pay insurers to create care management programs that prioritize the management of healthcare expenses rather than patient care.

As just one of many other examples of care coordination, the medical and behavioral health administrative services organizations (ASOs) which contract with the Connecticut Medicaid agency provide care coordination to patients for whom a referral is made, or sometimes based on their own review of hospital utilization patterns. The ASOs are not paying for the actual health services – the state does that – but rather states pay ASOs to ensure that individuals are receiving appropriate treatment, which can include care coordination. Such care coordination may well result in substantial savings to the state’s Medicaid budget. (An ASO is a business that provides a specified set of administrative services for a specified fee and does not bear financial risk.)

Section 1C: Connecticut eliminated its Medicaid MCOs in 2012, with resounding success

The state of Connecticut offers a solid example of the financial and health benefits of removing MCOs from Medicaid. In 2012, the state terminated its contracts with MCOs and began paying providers directly. In the 13 intervening years, the state reports that it has saved taxpayers more than $4 billion. 20 The state’s administrative overhead no longer includes any MCO overhead – it is now defined by its own agency administrative overhead – which has continued to fall. In 2018, CT spent $395 million on overhead 21; by 2022 it had fallen to $353 million. 22

When Connecticut eliminated MCOs from its Medicaid program, the state also provided better support to primary care physicians managing their own patients’ healthcare. Physicians are far more aware of their patients’ overall medical and social circumstances than insurance companies. The state demonstrated an immediate reduction in total administrative costs after terminating its MCO contracts and reduced its total per-capita costs. Lower per-capita costs were largely attributable to both lower administrative costs and improved physician participation and thus improved access to primary care, associated with lower ER and hospitalization costs. 23 Six years out, in 2018, its total per-member costs including both administration and health care, were 14% less than in 2012, its last year with MCOs. 24

More than a decade later in 2024, despite being an overall high cost state, Connecticut reported overall Medicaid costs that were 14% lower than all Northeast states (including New England, New York and New Jersey), almost all of which rely upon MCOs. 25

Section 2: Calculating the projected state savings from deprivatization

Section 2A: Calculating the overhead of MCOs today

By eliminating MCOs from Medicaid programs, states will avoid the cost of MCO overhead (defined here as the sum of all administrative expenses and profits). According to a report by Milliman, an independent health policy research firm, an average of 87 percent of all Medicaid MCO revenues were spent on medical care between CY 2015 and CY 2024. This is depicted in Chart 1 as the MLR, or Medical Loss Ratio. MLR is an industry standard term for the portion of an insurance budget that is spent on medical, not administrative, expenses. There is some ambiguity as to which services fall into which category. 

As described in the Milliman report, 87% is less than the 91.3% fraction calculated by CMS for the same time period due to differences in accounting for expenses such as those related to healthcare quality improvement, taxes, fees, and other items.

We interpret Milliman’s reporting of an 87% MLR to mean that 13% of all MCO revenue was diverted to MCO overhead. 26

Chart 1: Five-year historical financial results, per Milliman (“Figure 3” in Milliman’s report)

We believe an estimate of MCO overhead at 13% to be conservative for several reasons: 

  • Milliman’s analysis may fail to adjust for the capital reserves MCOs maintain, not directly replicated in a state-run Medicaid program. These are substantial, but vary widely by state. 27 These capital reserves can in some cases be treated for accounting purposes as expenses to be included in the Medical Loss Ratio calculations. This means that capital reserves may enable the MCO to clear minimum MLR hurdles in states that mandate them. If an MCO is running at an MLR of 82 percent, capital reserves can push the MCO above the regulator’s 85 percent threshold.
  • A 2022 Office of Inspector General report (OIG) 28 report describes widespread under-reporting of administrative expenses by Medicaid MCOs, a problem not addressed in Milliman’s report.
  • Milliman’s estimate of 13% overhead is lower than the overhead seen in Medicare Advantage, the other large public health program with MCO intermediaries. Both the GAO (Government Accountability Office) 29 and MedPAC (the Medicare Payment Advisory Commission) 30 report Medicare Advantage insurers operate with an overhead of 14%.

The savings states will achieve from no longer paying MCOs’ 13 percent overhead will be affected by changes in both state agency overhead and beneficiary utilization of medical services. We examine each of those factors in the next two sections.

Section 2B: Impact on agency overhead

As indicated in Tables 1 and 2, change in the Medicaid agency’s overhead costs also affects the net savings for a state. 

Deprivatization would reduce state overhead from no longer overseeing and managing MCOs, but states would also incur new overhead for assuming the operations of the MCO portion of their Medicaid programs, e.g., claims adjudication and other basic functions. MACPAC provides data on each state agency’s administrative costs, but there is little public information on what portion of these costs are attributable to regulating MCOs and what portion to other tasks. 31

Federal law and regulations impose numerous regulatory obligations on Medicaid agencies that administer privatized programs. These obligations add to agency overhead. But agency overhead is reduced by the cost of functions assumed by MCOs instead of directly by the state Medicaid agency. MCOs assume the cost of claims processing, any prior authorization determinations the state chooses to adopt, consumer services, and other functions.

The 2024 MACPAC report shows spending on agency administration (federal plus state combined) in Connecticut represented 3.8% of total Medicaid expenses – the same as the national average. 32 This data is difficult to interpret as there is wide variation among Medicaid program design and implementation, but it suggests that Connecticut’s comprehensive deprivatization will have minimal impact on overall state agency overhead.

Another way to look at this is to consider what Connecticut currently spends on the administrative functions that it took over from MCOs and now contracts to an ASO. Connecticut contracts with three ASOs, one to administer medical services, one to administer behavioral health services, and a third to administer dental services. Based on 2017 data from the CT Medicaid agency, the annual payments to all three ASOs equaled $107 million, or roughly 1.7% of the state’s total $6.096 billion in Medicaid expenditures that year. 33 A minority of this is for care coordination; most is for prior authorization, customer service, provider recruitment, etc., activities which are not optional even under a traditional fee for service program. In addition, there are new administrative costs for taking over claims processing from the MCOs. 34 We estimate that half of the claims processing costs shown in 2017 were new from deprivatization, based on the shifting of the child/family population out of MCOs, while the state was already providing claims processing for the smaller elderly/disabled population, which has higher claims experience. Total administrative cost for taking over the MCOs’ mandatory functions is therefore estimated to be 1.9% of the Connecticut Medicaid budget that year, though the percentage of the CT Medicaid budget covering ASO contracts has since become lower.  

Based on this experience, we estimate that the new administrative costs agencies incur after deprivatization will likely slightly outweigh the savings from no longer having to regulate MCOs. In the absence of research on this issue, we have chosen to add 1-2% percent to agency overhead. The states that move their Medicaid program from MCOs over to ASOs might add as much as 2% for new administration, at the high end, while also saving significant sums on avoided MCO oversight.

In summary, MACPAC data suggests a 1% decrease in Medicaid agency costs; CT’s experience suggests no more than a 2% increase in new state agency administrative expenses related to health care delivery, even when a robust care coordination program is included.

Data on the overhead costs of North Carolina’s Medicaid agency before and after privatization of its Medicaid program is very similar to the Connecticut data we just reviewed. Like Connecticut, the deprivatized (direct payment) program that North Carolina administered included a state-run care coordination program. After the North Carolina legislature privatized its Medicaid program, the agency’s overhead remained unchanged: It was 5.5 percent before and after privatization.

Section 2C: Impact on utilization

The very limited research on the impact privatization has on utilization of medical services indicates MCOs reduce healthcare utilization by zero to five percent of spending compared to unmanaged fee for service. 35,36,37 Isolating the direct change in utilization, as difficult as that is, only yields an incomplete picture of the true impact of changes in utilization. MCOs apply very blunt tools that reduce both medically necessary and unnecessary healthcare expenses. According to one report concerning Medicare Advantage, half of services denied by insurance companies are medically necessary care. 38

States seldom oversee the appropriateness of MCO prior authorization. A 2023 report from the Office of the Inspector General (OIG) states:

We recommend that states implement their own care coordination interventions and enhancements to care delivery, including recruiting more primary care practices to participate in Medicaid. If states introduce or expand these programs, they can reverse any increase in utilization stemming from the removal of MCOs. They can improve utilization of preventive medicine, decreasing ER visits and hospitalizations. One extensive review suggests improved access to primary care produces significant reductions in overall expense. 40

Although the transition into MCOs thirty years ago led to about a 5% decrease in utilization, the reverse is unlikely. States need not anticipate a comparable increase in utilization when they move from MCOs to fee for service, particularly if they adopt our recommendation for managed fee for service. 

It is unclear how much, if at all, utilization would rise absent MCO programs. Medical practice patterns have shifted since the introduction of managed care, and at least one test of a temporary pause in utilization management programs did not demonstrate any rise. In 1989, New York City and its unions temporarily switched 50% of the participants in its health insurance’s comprehensive utilization management programs into sham programs. “Actual utilization review and sham review may both have decreased the use of hospital services, with patients or their physicians choosing more efficient treatment when they believed that care would be reviewed.” 41

The limited supply of physicians in a geographic area constrains increases in utilization, as was documented both with the expansion of the population of Americans with insurance after the enactment of Medicare and Medicaid in 1965 and the Affordable Care Act in 2014. 

  • Per capita physician visits for the periods before and after Medicare and Medicaid were enacted were virtually identical (427/100 person years from 1963 to 1965 versus 425 /100 person years in 1966-1970). The small increase in visits for seniors and people with low income (399 to 408) was balanced by a decrease in visits for everyone else (450 to 442). 
  • The same pattern was observed with the enactment of the Affordable Care Act with 372 physician visits / 100 person years in 2011 – 2013 and the identical 372 visits / 100 person years in 2014 – 2016. 42 We infer that physicians are already working at capacity; eliminating managed care from Medicaid is unlikely to drive a meaningful increase in utilization. 
  • When Connecticut deprivatized their Medicaid program, the number of physicians didn’t increase – but physicians participation in Medicaid increased a lot. If a state doesn’t enhance primary care pay and implement real care coordination programs there may be no increase in physician participation in Medicaid, and therefore minimal increase in utilization with de-privatizing alone.

We project up to a 2% increase in utilization in states that shift to unmanaged fee for service, roughly half of which is likely to improve the health of Medicaid recipients, which in turn may reduce future spending. Because these savings develop over time, our projection in Table 2 includes a range for the impact on utilization. 

For a more in depth discussion of the impact of state-run care coordination programs on utilization, see Appendix E: “The truth about Medicaid managed care.”

Section 2D: Impact on total state spending

An analysis of CMS data from 2004 to 2015 in counties that moved their high-risk Medicaid population from fee for service into mandatory managed care found a sustained increase in total spending on Medicaid. “We find that while fiscal costs decrease by $29 (2.2%) per member per month (PMPM) during the first mandate year, they continuously increase afterwards. By the fourth post-mandate year, counties with an enrollment mandate experience higher fiscal costs of $132 (9.8%) PMPM, compared to counties that maintain the public FFS system for disabled beneficiaries…. These results provide no support to the claim that managed care mandates save costs for the Medicaid program, outside of the first implementation year. Instead, they suggest that mandates lead to a dynamic pattern of increasing spending.” 43

Chart 2. Total spending before and after managed care enrollment mandates

Note: Chart shows the difference in total spending between treatment counties and control counties, relative to the year before the mandate. Year zero is the first year in which the mandate is in place (denoted by a vertical dashed line) and shows the dollar differences between treatment and control in the total Medicaid spending PMPM.

These findings are similar to an analysis of state and local mandates from 1991 to 2009 that required most Medicaid recipients to enroll in an MCO, concluding “shifting Medicaid recipients from fee-for-service into MMC [Medicaid Managed Care] did not on average reduce Medicaid spending. If anything, our results suggest that the shift to MMC increased Medicaid spending and that this effect was especially present for risk-based HMOs.” 44

Section 2E: The bottom line

As Medicaid is jointly funded by states and the federal government, a portion of the savings accrue to each party.

Table 1. Calculation of net savings to states from deprivatization in states that adopt unmanaged fee for service (not recommended)

*Some costs increase, others decrease.

Table 2. Calculation of net savings to states from deprivatization in states that adopt managed fee for service (recommended)

**Just as in unmanaged fee for service, utilization in managed fee for service may increase in the short term but, under well-managed fee for service, is likely to decrease over time. Connecticut demonstrated improved physician participation and reduced ER and hospital costs, even in the first year. 45 (A poorly managed program might have less positive results.)

Section 3: The impact of capitation on Medicaid budgets, access, and quality

Section 3A: Capitation does not protect state budgets

The basic model of insurance is the distribution of the expenses of infrequent high-cost care across a wide population. In the pursuit of market competition and patient choice, and as required by federal Medicaid law, states capitate multiple MCOs, fragmenting their large state-wide risk pool into smaller populations. This can introduce wider swings in average medical expenses. In a fragmented system, the cost of one large case, e.g., an organ transplant or an extended stay in a burn unit, has fewer people to be distributed across and creates larger fluctuations in total population costs. This fragmentation into smaller subpopulations for the distribution of insurance risk reduces budgetary predictability and therefore requires larger “rainy day” financial reserves, eroding one of the efficiencies of a single state-wide program.

States do not control costs effectively by paying an MCO on a per enrollee basis. The two largest drivers of a state’s Medicaid budget are changes in enrollment and benefit design. States cannot save money on these changes by paying MCOs a capitated rate. 46

Much of the information required for states to regulate managed care contracts effectively, such as how much the MCOs are paying their contracted providers, is considered proprietary by the MCOs and deliberately remains opaque to both regulators and legislators:

Some lack of transparency in MCO behaviors may be mitigated by the Budget Reconciliation Act, but implementation is always a challenge with legislation.

Given the upheaval in federal Medicaid funding, this is an opportune moment for states that privatized their Medicaid program to reconsider the design of their Medicaid delivery model. The potential financial savings to the states is substantial. Fortunately, there are successful examples to learn from.

Section 3B: Capitation creates perverse incentives to obstruct access to care

MCOs are allowed to retain all or significant portions of the difference between their capitation revenue and actual medical expenses. This creates a financial incentive to reduce all healthcare services – including care generally considered as medically necessary. 48

Proponents of privatization argue that capitation encourages more prevention and other health maintenance services. Unfortunately, Medicaid MCOs know that their typical enrollee will remain in Medicaid for less than ten months, meaning the MCO gets no benefit from avoiding future medical expenses. 49,50 Investments in a program that might improve long-term health outcomes exposes an MCO to the cost of the program but guarantees none of the savings. In addition, publicly-traded MCOs tend to focus on the immediate quarter’s profits, so possible returns in the future from investments in an individual’s health are unlikely to be motivating, even if the individual stays in the MCO’s plan. In contrast, MOCs often see immediate cost-savers, such as denying prior authorization requests, as more reliable sources of remuneration.

Additionally, the 2025 Budget Reconciliation Act will require more frequent eligibility determinations, increasing the turnover rate among Medicaid enrollees and further eroding the relevance of long-term health improvements. Before the Budget Reconciliation Act, states typically reevaluated Medicaid eligibility on an annual basis. Under the new law, states will be required, starting in 2027, to repeat this process at least twice yearly for their Affordable Care Act expansion populations (primarily childless adults). They also are required to impose new frequent work reporting requirements on expansion population enrollees. Given the complexity of meeting those demands, millions of people who are eligible for Medicaid are expected to lose their insurance. Among other major concerns, this is likely to further shorten how long individuals remain enrolled in Medicaid, further reducing any financial benefits the MCO could reap by improving the long-term health of the population.

Section 3C: Capitation’s impact on utilization of healthcare services

MCOs, especially Medicaid MCOs, frequently use prior authorization (PA) as a tool to regulate access to certain health care services and prescription drugs. MCOs claim that PA is necessary to limit unnecessary utilization and help control costs. However, the use of PA in Medicaid managed care has raised significant access concerns: higher denial rates, inconsistent oversight, and variability across states and plans. Medicaid MCOs deny services at much higher rates than Medicare Advantage MCOs or insurers in the private sector. 51 Some Medicaid MCOs had denial rates exceeding 25%, critically compromising access to care. 52,53

Although the data show that Medicaid MCOs deny care at a high frequency, there is little research on the impact of these denials. However, there is robust data on the role of MCOs in the Medicare Advantage (MA) program. In 2024, MCOs enrolled roughly half of the Medicare population in Medicare Advantage plans 54 and required prior authorizations for 50 million services, compared to 400,000 services in traditional Medicare. 55 In MA plans, MCOs denied the request for authorization 6.4% of the time, creating 3.2 million battles for physicians to provide care to their patients. 56 Although MCOs are required by law to cover the same services as traditional Medicare, the OIG found that 13% of service denials in Medicare Advantage would have been accepted in traditional Medicare or were a flawed decision. 57

When patients appeal a denial of services, Medicaid MCOs find many of their initial denials inappropriate. A recent report concluded that Medicaid MCOs overturn 46% of these denials. 58

PA creates an unnecessary and overwhelming burden on physicians, not only taking an emotional toll, but also cutting into the time they have for direct patient care. In a 2001 lawsuit brought by Connecticut doctors against MCOs, the plaintiffs identified the burdens imposed upon them by PA as a significant factor in their willingness to serve patients insured by MCOs. 59 89% of physicians in a 2024 American Medical Association reported that prior authorization increases burnout. 60 Similarly, Medicaid MCOs impose excessive work on physicians and prevent the delivery of necessary care. 

Medicaid MCOs also make it challenging, if not impossible, for states to know how limited the MCOs’ networks are because provider directories are inaccurate. There is a prevalence of “ghost networks”– insurance directories that list healthcare providers who are not actually available to patients either because they have retired, moved, are no longer accepting the insurance, are not taking new patients, or have outdated contact information. MCOs have been aware of this problem and have allowed it to persist for many years. CMS has new requirements that attempt to address this, though it is too early to assess the impact and beyond the scope of this report to review.

In 2014, the OIG found that more than half of the providers listed by Medicaid MCOs as in-network were not able to offer appointments to enrollees. Notably, 35% of the providers were unable to be found at the location the MCO provided, 8% said they were not accepting any new patients, and 8% stated they were not even enrolled in the MCO plan. 61 A 2023 study of five large health insurers found that 81% of entries had inconsistencies, such as address errors or the wrong specialty being listed for a physician. 62 A New York Attorney General’s report found that 86% of mental health providers listed on health plans’ directories were “ghosts.” 63)

The existence of these “ghost networks” is directly tied to broader issues of network inadequacy in MCOs, causing care delays that harm patients 64, including worsening health and death 65, financial and emotional harm 66, care abandonment, trust erosion 67, and an increase in health inequities. 68

It’s harder to get care when there are relatively few physicians accepting Medicaid patients in most states, placing a burden on a small group of providers. Only 74% of physicians nationally accept any patients covered by Medicaid, compared to 88% for Medicare and 96% for private insurance. 69 Retaining physicians in the program is difficult; more than one third of providers exit within five years. 70 This lack of continuity poses a barrier to high quality care.

Physicians cite the administrative burdens of Medicaid managed care PA requirements, not low reimbursement rates, as the primary reason they do not accept Medicaid patients. 71,72

In 2009, Hawaii converted most of its Medicaid population with serious mental illnesses to MCOs. Within four years, nearly all Hawaii psychiatrists in independent practice had stopped accepting new Medicaid patients. Hawaii’s ER and hospital costs for serious mental illness had risen by 30%. 73

The Connecticut experience suggests a better way forward. According to Ellen Andrews, PhD, executive director of the Connecticut Health Policy Project:

According to a December 2024 review of Connecticut’s managed fee for service program by Manatt Health, 97% of providers report being  “satisfied… with the administration of the HUSKY Health program,” compared with 65% reporting satisfaction in a broad national survey. 75

Section 3D: Assessing quality in MCOs

Because capitation gives MCOs an incentive to deny and delay services, meaningful assessment of quality is a necessary component of a capitation contract. 76 Accurate measurement of MCO quality is difficult for several reasons and published reports are often discredited by academic reviewers 77:​​

  • Incomplete MCO data for states to review: Medicaid agencies often cannot get complete data from MCOs on services MCOs provide and the outcome of those services. As private corporations, MCOs are allowed to obscure or limit the data they provide. 
  • Bundled product problems: Health insurance covers thousands of services, but MCO quality measures attempt to assess the quality of only a tiny fraction of all those services.
  • Risk adjustment problems: Scores on quality measures need to be adjusted to reflect factors outside of MCO control. This is known as risk adjustment. But despite four decades of research on risk adjusters, accurate risk adjustment remains elusive. MCOs are known to manipulate the data reported on claim forms to justify higher capitation rates. In addition to the economic burden this imposes on states, it confounds objective measurements of quality.

Section 3E: Capitation conflicts with investing in improving healthcare quality and clinical outcomes 

Connecticut’s experience demonstrates that states can perform well without MCO middlemen. The state’s Medicaid program scores above the national average on 68% of federal quality measures and in the top quarter for almost half (47%) of the measures. Its Medicaid program (called “HUSKY”) ranks very well on primary/preventive care, maternal/parental health, and oral health. 78 CT generally performs well on the core set of measures applied by CMS compared with other states. A 2024 report found that CT’s program demonstrated “[s]trong performance on most national adult and child performance measures compared to median state performance.” 79

New Jersey maintained its Medicaid MCO program at the same time that CT ended its MCO contracts in 2012. As seen in Chart 1 below, prior to the change in CT, the two states had comparable rates of early cancer diagnoses. After they made their change, CT saw a 4.7% increase in early cancer detection and an 8% higher survival rate compared to New Jersey. 80 The difference in these outcomes has been attributed to reducing prior authorization delays and other MCO-driven delays in accessing cancer care. 81

Chart 3: Early-Stage Cancer Diagnosis 82

Research on the privatization of CA’s Medicaid program and the deprivatization of OK’s Medicaid program confirm CT’s experience with deprivatization.

  • California Medicaid enrolled older adults and those with disabilities in MCOs between 2011 and 2012, affecting ~240,000 enrollees. This resulted in a rise in emergency department visits and a 12% increase in mortality over the next three years. 83
  • Oklahoma started moving its Medicaid population from MCOs into Primary Care Case Management in 2003. This resulted in improved access to preventive services, primary care, and early prenatal care, along with an expansion of the rural provider network. Over the next three years, ER utilization in Oklahoma Medicaid fell by 5% while increasing in Medicaid nationally by 9% 84, demonstrating the value of better care coordination and access to timely services.

Section 4: The transition to managed fee for service can be relatively rapid

  • Every state currently has some operational capacity for fee for service Medicaid, typically for their aged and disabled populations. In 2023, 25.4% of the country’s Medicaid enrollees were not covered by MCOs and were managed through already existing state-run infrastructure. 85 This infrastructure, expanded and enhanced with care coordination, can provide an operational foundation for deprivatization. 
  • After two years of consideration 86, the Oklahoma board overseeing Medicaid decided on November 7, 2003 to remove MCOs effective on December 31 2003, and fully transitioned to statewide Primary Care Case Management over the first four months of 2004. 87
  • Connecticut demonstrated that removing MCOs from Medicaid and strengthening its fee for service operation can be successful in the first year. In February of 2011, the Governor announced the decision to terminate the state’s MCO contracts and instead contract with non-risk ASOs supplemented with “Patient Centered Medical Homes,” a team-based expansion of primary care intended to improve outcomes (with mixed evidence). 88,89 In January of 2012, 11 months after the governor’s announcement, the transition from MCOs to managed fee for service and the ASO structure was completed. 90 Benefits were seen in the first year.

Section 5: Pharmacy is both an opportunity and a challenge

An important consideration for some states interested in deprivatizing their Medicaid programs is the potential for political opposition from local hospitals and clinics that participate in the federal 340B Drug Pricing Program. The 340B program enables “covered entities” (defined in statute as hospitals in under-resourced communities, Federally Qualified Health Centers, and a few other entities) 91 to buy medications at a deep discount and retain the difference between the reimbursement paid to them by MCOs and their discounted purchase price. 

Current federal rules do not allow covered entities to earn 340B “savings” from Medicaid fee for service programs, but 340B covered entities can earn 340B “savings” from MCOs. 92 This provides a financial incentive for local hospitals and clinics to oppose any state reform that would place more Medicaid enrollees under fee for service. This political dynamic was seen in recent Medicaid deprivatization efforts in California 93 and New York 94,95,96 as well as failed Medicaid deprivatization efforts in Minnesota and Utah.

Some states have been stymied in their efforts to mitigate hospital concerns. One state’s anecdotal proposal to “keep the hospital whole” by passing any savings they collect back to the hospitals was countered by two concerns: hospitals see the current 340B model as reliably ensured by federal statutes and therefore do not consistently trust their states to continue their promises indefinitely. Hospitals also are unsatisfied by “being kept whole” as they anticipate continued growth in the program. Indeed, the 340B program funding is expanding rapidly, increasing by 23.4% ($12.6 billion) from 2022 to 2023. 97 Some analysts describe the 340B program as having “gone off the rails” with “unchecked growth and unintended consequences.” 98

These increases may not last forever; states have multiple mechanisms to decrease or eliminate the ability for 340B covered entities to earn 340B revenue from MCOs through variations on which types of covered entities, which type of pharmacies, and which types of claims are allowed under Medicaid Managed Care. 

The intense lobbying from covered entities to defeat Medicaid deprivatization and protect their access to 340B rebates is understandable. Across the country, covered entities stand to lose $6.5 billion in revenue. Because a large portion of the Medicaid program is federally funded, $4.2 billion of this would be new federal revenue and the remaining $2.3 billion would be distributed among the states, as broken out in Table 3 below. 99 As state Medicaid budgets become increasingly fraught, states may simply find it unacceptable to continue to ignore these funding opportunities. 

The competition for these 340B rebates (between state agencies and covered entities) demonstrates how fragmentation can create conflict between groups who may otherwise be allies.

Table 3: Managed Medicaid Rebates Ineligible Due to 340B Drug Pricing Program (estimated as of 2024) 100

“N/A” indicates that the structure of these states’ Medicaid programs means that they do not incur costs due to the 340B program

Section 6: State examples

Section 6A: North Carolina

North Carolina has gone back and forth on privatization of its Medicaid program. During both stages, its program has been known as Community Care of North Carolina (CCNC). 

As a deprivatized model, CCNC was a partnership between Medicaid, primary care physicians, and other local health care providers. CCNC was a grassroots response by physicians, community health care leaders, and state policymakers to meet the challenge of providing cost-effective high-quality care for Medicaid patients, and for years it worked well. 

CCNC initially started in 1988 as a demonstration project in Wilson County, funded through a charitable trust. When that project was successful, the state applied and was approved for a 1915b Medicaid waiver to roll out the demonstration project more widely to other counties. The model that the state found to be most successful, and was eventually the structure that the entire program was modeled after, required participation by enough practices to care for at least 70% of Medicaid patients in the community. Additionally, local hospitals, county health departments and departments of social services were required to participate. These entities created fourteen individual networks that were able to respond to the specific needs of their region. Physicians in medical management committees developed initiatives and monitored the statewide progress of these initiatives, making revisions as needed.

The driving impetus behind North Carolina having a deprivatized state-run model came from discussions about block grants and managed care systems taking over the North Carolina Medicaid system. This pushed physicians, who were worried about severe cuts in reimbursement and loss of independence, to try to maintain local control through a community care model. 

According to a 2015 report from the North Carolina state auditor, “Between 2003 and 2012, CCNC saved about $312 annually for each Medicaid recipient, while keeping people out of the hospital…. The report showed upwards of $122 million in savings in the first year and a 9% reduction in spending over the entire time period, which works out to more than $320 million in 2012 alone.” 101

North Carolina achieved its largest savings in ED utilization, outpatient care, and pharmacy expenditures. The program received accolades and in 2007 was awarded the Annie E Casey award and Harvard University’s Innovations in American Government Award. 

In addition to the financial impact of deprivatization in North Carolina, deprivatization also drove a marked increase in the number of primary care physicians willing to treat patients with Medicaid. As described by Thomas White MD, president of the North Carolina Academy of Family Physicians in a press release after the report was made public, “Today [2015], over 90 percent of our state’s primary care physicians serve Medicaid patients. They do so in part because of the efficient delivery system we’ve built.” 102

Despite these achievements, in 2015 North Carolina Governor Pat McCrory signed House Bill 372 (Senate Bill 574) into law, which began the process of privatizing the state’s Medicaid program. 103 The state claimed that this change aimed to improve budget predictability, control costs, and promote better health of enrollees by paying insurers based on health outcomes rather than individual services rendered. 

Privatization began in 2015 and was officially completed on July 1, 2021 104 (during the COVID pandemic), covering most Medicaid enrollees through commercial health plans, although like most states they retained their high-risk population in the state-run fee for service program called “NC Medicaid Direct.” 105

MACPAC reports that North Carolina’s administrative expenses as a portion of the total cost of their Medicaid program has remained flat at 5.5% in FY 2015, FY 2021, FY 2022, and FY 2023. 106 This spans several years prior to transitioning to a privatized system and persisted at least two years after the transition. On balance, the expense of Medicaid administration in the state of North Carolina was unchanged by the switch to a privatized system. Logically, the inverse would also be true for a state that moved in the opposite direction.

We infer that a state that deprivatizes its Medicaid program and adds a publicly run care coordination program would see little change in the overhead of the Medicaid agency.

An Urban Institute analysis of the first year of North Carolina’s Medicaid MCO transition reported numerous predictable problems 107:

  • Individuals with complex behavioral or physical health conditions faced difficulties  finding plans that covered their preferred providers and specialty services, among other challenges. Some enrollees with complex behavioral health needs had to be re-enrolled in Medicaid Direct to maintain access to necessary benefits.
  • Many providers limited participation to certain health plans as a result of administrative burdens associated with contracting and billing with MCOs. This affected access to care, as enrollees sometimes struggled to find in-network providers.
  • Enrollees reported disruptions in their access to prescription medications. An increase in prior authorizations caused delays and denials that affected high-need patients. Enrollees also faced unexpected out-of-pocket costs as a result of having to turn to providers outside of the MCO network.
  • The added administrative complexity led to confusion for both the providers and the patients. Providers expressed frustration because of the different coding, billing, and prior authorization requirements of each health plan.

Section 6B: Other states

A 2004 review of California’s mandate for the majority of Medicaid beneficiaries to enroll in an MCO demonstrated “the average effect of the switch in enrollment induced by the mandate was to increase Medicaid spending by approximately 17%.” 108

In 2022, Ohio removed pharmacy benefit managers from their Medicaid program. Milliman reports that Ohio saved $140 million net over a two-year period – $330 million in total administrative cost savings – while boosting the dispensing fees they pay to retail pharmacies by 1200% and significantly expanding their network of Medicaid-participating pharmacies. 109

Reports from the privatization of Medicaid in both Kansas and Iowa describe a failure to achieve projected cost savings, reduced access to medically necessary care, a lack of oversight and transparency, and a loss of due process. 110 In both Kansas and Iowa, privatization of Medicaid resulted in an increase in claim denials, reduction in services, and delays in payments to providers. 111,112 An Iowa survey of 400 doctors, hospitals, local clinics and non-profit health care providers showed that only four months into privatization, 90% reported that privatization had increased their administrative costs, 79% were not getting paid on time, 66% said they were paid lower rates than was agreed upon, and 61% said privatization reduced the quality of services they could provide. 113

Section 7: Conclusion

Winston Churchill is often quoted as saying “Never let a good crisis go to waste.” 114 The cuts to Medicaid that were authorized in the 2025 Budget Reconciliation Act are indeed a crisis for patients, physicians, and state governments. The Budget Reconciliation Act unfortunately targeted patients in need of Medicaid coverage rather than waste and fraud among insurance companies with documented patterns of gaming federal health programs like Medicaid and Medicare out of  hundreds of billions of dollars. States can respond to the reductions in federal Medicaid funding with their own austerity measures that target individual patients and wreak profound harm on their most fragile population. Or states that have privatized their Medicaid programs can find savings by enacting reforms to deprivatize Medicaid and improve the health and finances of their state. We propose the latter, and hope this report guides the way.

States’ reliance on MCOs in their Medicaid programs has raised costs and deprioritized the long term health  of their Medicaid populations. This experiment should be recognized as a failure. Insurance companies have not fulfilled their key promises. Fortunately, managed fee for service is a proven alternative. Rather than returning to a traditional direct payment Medicaid model, deprivatizing Medicaid is best organized in conjunction with a modest investment in care coordination programs that both lower total expense and improve health outcomes. Patients would have fewer barriers to care, greater access to teams of providers, meaningful coordination of care across the complex healthcare landscape, and would reap the diverse benefits of improved health.

Appendices

APPENDIX A: Glossary

ASO (Administrative Services Organization) is a business or non-profit entity that provides administrative support to other businesses or governmental agencies for a specified fee. In health care, ASOs are often contracted to provide administrative services such as claims processing or prior authorization reviews but do not take on financial risk for the cost of healthcare.

Care Coordination is identified by the National Academy of Medicine as a key strategy with the potential to improve the effectiveness, safety, and efficiency of the health care system, encompassing care management, teamwork, medication management, assistance with transitions of care, assistance with transportation, monitoring and followup, linkages to community resources, and multiple other activities. 115 These services are typically performed by physicians and other health care professionals and are paid directly by a state Medicaid program.

Care Management programs are often included in capitation contracts with the intention of improving the delivery of patient care, but being part of the capitation leads to prioritizing the management of healthcare expenses rather than patient care.

FFS (Fee for Service) is a payment model where healthcare providers are directly paid a separate fee for each unit of service they deliver.

FMAP (Federal Medical Assistance Percentage) is the fraction of a state’s Medicaid program costs that are funded by the federal government. Generally determined annually, the FMAP formula is designed so that the federal government pays a larger portion of Medicaid costs in states with lower per capita incomes relative to the national average (and vice versa for states with higher per capita incomes). FMAP rates have a statutory minimum of 50% and a statutory maximum of 83%. 116 The Affordable Care Act enhanced the state FMAP to 90% for the portion of a state’s Medicaid population that was added under that law’s Medicaid expansion. 117 The Families First Coronavirus Response Act provided a 6.2 percentage point increase to states’s FMAP, effective from January 1, 2020 until the end of the COVID public health emergency. 118

Managed Care Organizations (MCOs) are health insurance plans intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased patient cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. 119

Managed Fee for Service is a healthcare payment model that retains the fee for service payment structure but adds initiatives to enhance clinical practice, improve coordination of care, and improve quality, likely resulting in a reduction of avoidable costs. 120

MACPAC (Medicaid and CHIP Payment and Access Commission) is “a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, the Secretary of the U.S. Department of Health and Human Services, and the states on a wide array of issues affecting Medicaid and the State Children’s Health Insurance Program (CHIP).” 121

MedPAC (Medicare Payment Advisory Commission) “is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.” 122

MLR (Medical Loss Ratio) is defined by the Affordable Care Act as the share of health care premium revenue that health insurance companies spend on clinical services and quality improvement expenditures. The Congressional Research Service discusses what CMS considers allowable quality improvement to be included in the MLR. 123 There is a substantial difference between a statutory definition of MLR for CMS vs the actuarial definition of MLR for business applications. 124

Overhead of an insurance company is generally the inverse of MLR and encompasses all non-medical expenses, such as administrative costs, employee salaries, office rent, marketing, advertising, and profits. Overhead excludes the cost of clinical services. 125

There is some ambiguity in the calculation of MLR vs overhead. This distinction has both clinical and financial implications. “For the purposes of the MLR calculation, ‘medical care’ consists of clinical services and quality improvement efforts. Since the MLR must be 80-85%, there is an incentive for insurers to spend more, up to a certain point, on medical care and ‘quality improvement.’ Prior authorizations, where an insurance company must approve a proposed medical service before the provider executes it, count as quality improvement. However, there is little evidence that the majority of prior authorizations result in higher quality care or improved health outcomes, and in fact, many providers believe it does the opposite.” 126

PMPM (Per Member Per Month) is a metric used in the healthcare industry to express the average monthly cost for each individual covered under a health insurance plan. It is calculated by dividing the total healthcare costs for one month by the number of people enrolled in the plan during that month. It is used to establish the rates at which capitated MCOs are paid based on the number of enrollees in a plan in a given month.

APPENDIX B: Guidelines for states developing legislation to deprivatize Medicaid

The specific circumstances of each state’s current Medicaid program, combined with their local culture, politics, and economics, make it beyond the scope of this report to propose model legislation for each state to adopt. In this section we provide guidelines and recommendations for what states need to consider in drafting their own legislation, understanding that some states may wish not to be very prescriptive. 

An example of a starting point for a state wishing to develop a managed fee for service program, the 2025-2026 Minnesota state legislature is considering a similar bill, SF1059. 127

As another example, Connecticut authorizes the state’s Medicaid agency to “contract with one or more ASOs to provide care coordination, utilization management, disease management, customer service and review of grievances for recipients of assistance under the HUSKY Health program. Such organization may also provide network management, credentialing of providers, monitoring of copayments and premiums and other services as required by the commissioner.” 128

  1. States must prohibit the initiation or renewal of contracts with MCOs and all other entities that bear any financial risk.
  2. Providers should be paid directly by the state entity managing the new Medicaid program. 
  3. The legislation needs to define care coordination (which must include physicians,  community health workers, nurses, and other licensed care providers that are essential to a properly functioning care coordination system) that can respond flexibly in the community to the needs of individual patients.
  4. States should authorize their Medicaid agencies to pay health care professionals for care coordination and related services. Examples include a managed fee for service program similar to Connecticut’s model using ASOs, or through an enhanced primary care case management system similar to North Carolina’s former system without ASOs. With either approach, there should be no intermediaries that bear financial risk. Key features for a successful care coordination program: 
    • Ensure that providers will be fairly compensated in a timely manner.
    • Practices that are approved by the State to coordinate care may receive extra funding for documented care coordination services. 
    • Create funding streams for community outreach to help create care coordination programs within communities.
    • Care coordination teams should include licensed community-based human resources that are readily accessible to primary care practices, with a mission to interact with primary care practitioners and their patients.
    • Care coordination teams should also serve specialty and subspecialty consultants in collaboration with primary care practices.
  5. Public health functions should continue to be provided directly by the state for population health needs (e.g., vaccinations and disease control). 
  6. Administrative functions need to be provided directly by the state or a contracted ASO for oversight functions such as quality improvement, customer service, and review of grievances. (Grievances about an ASO itself would need to be handled directly by the state Medicaid department.) If the state chooses to contract with ASOs, the ASOs should be prohibited from establishing their own provider networks; there should be only one statewide provider network available to all enrollees, though the ASO may assist enrollees in obtaining access to providers in the unitary network.
  7. States should develop regional hubs that meet periodically to discuss community health needs and equitable access to care within their own region as identified by providers, nurses, and patients rather than insurance interests or other industry agents. This helps ensure that all communities are being served adequately and the state Medicaid agency is well informed. As developed by North Carolina, these regional hubs should  convene state-wide annual meetings to discuss the state outlook, identification of best practices, opportunities for improvement, and efforts to achieve these improvements. These annual meetings should include representation from the state Medicaid agency to ensure that everyone is on the same page and that the program remains fiscally sound while ensuring that the needs of all enrollees are being met. All meetings should be open to the public.

APPENDIX C: Alternatives to deprivatization of Medicaid

States have at least five other potential responses to the federal Medicaid budget reductions. Each of these alternatives would either be politically highly unpopular or would undermine the health and well-being of a state’s most fragile population and should not be adopted.

  1. Not recommended: Cut Medicaid eligibility. The 2025 Budget Reconciliation Act requires states to end Medicaid coverage for many categories of legally present immigrants in October of 2026, and to introduce work reporting requirements and more frequent redeterminations for all expansion populations in January 2027. This, plus other cuts, including the major additional cuts to states from cutting back on their provider taxes which currently leverage additional federal Medicaid dollars, is anticipated to reduce Medicaid eligibility by 7.8 million people. 129 Due to budget constraints, some states may be considering additional strategies to reduce eligibility.
  2. Not recommended: Cut Medicaid services. Most states include coverage for a range of “optional” services beyond the minimum statutory requirements for participation. 130 Optional services include pharmacy, dentistry, physical therapy, occupational therapy, and hospice care, among other vital benefits. Ironically, optional long-term home health services are among the first to go, which results in higher hospitalization and ER utilization. 131 As one example, California eliminated its comprehensive dental coverage from Medicaid in 2009 and saw a 32% increase in dental ED visits and increasing average yearly costs of dental ED visits by 68%. 132
  3. Not recommended: Cut Medicaid reimbursement rates. Many states already pay providers at rates that are so low it is difficult for people covered by their program to maintain reasonable access to care. 133 There is thus very little room to reduce these rates and still have a functioning program.
  4. Not recommended: Reduce funding for state programs outside of Medicaid. This approach puts states under pressure to choose among competing funding priorities.
  5. Not likely to be politically feasible: Raise general state taxes. Although some states may turn to this approach, many states have existing statutes or political climates that make this difficult, if not impossible.

Other than deprivatization, each of these alternatives either cuts services for individuals or increases taxes.

APPENDIX D: Research on Medicaid MCOs is difficult

  • Comparisons are deeply confounded. Unlike Medicare Advantage, which has traditional Medicare as a control group (an imperfect one, to be sure), Medicaid MCOs have no such comparison group. Interstate comparisons are confounded as states vary widely in the details of their programs. Longitudinal trends within single states are complex as benefit designs and eligibility are often shifting. Intrastate comparison of Medicaid MCO patients with the state’s Medicaid FFS patients is confounded as states generally exclude their higher risk groups (e.g., aged, blind, and disabled) from MCO capitations. 
  • States adopted Medicaid MCOs without rigorous testing or evidence of their efficacy. There are no studies done prior to Medicaid MCO adoption to show that MCOs would save money; additional comprehensive research would be helpful. Research on the true impact of MCOs on the financing of Medicaid remains neglected. 
  • Researchers sometimes fail to distinguish multiple causes of utilization or cost variance, conflating other changes with the impact of privatization. For example, in Texas, mandatory enrollment into MCOs was associated with a reduction in inpatient utilization. 134 The reduction in inpatient utilization is thought to be a consequence of improved access to prescription medications, which helped prevent the need for additional services, and not from capitation. “Prior to privatization, the state imposed strict rationing of drugs among public plan enrollees through a monthly limit of three prescriptions, while not imposing this limit on private plan enrollees and instead allowing the private plans to use their own utilization management methods… As rationing was relaxed for drugs and outpatient care in Texas, we find clear evidence that inpatient spending decreased by at least 8%.” 135

APPENDIX E: Comparison of MCOs vs managed fee for service

Section E1: Contracting with MCOs does not reduce a state’s financial risk or create predictable budgets. Perhaps one of the most frequently presented arguments by MCOs and state agencies which contract with them is that making capitated payments to insurers ensures predictability for the state and avoids spikes due to very high care needs by a few expensive patients. The MCOs argue that protecting the states from such fluctuations is a valuable service.  In reality, however, most of the fluctuation in expenditures under Medicaid are due to enrollment increases, not costs per person, and this risk is not borne by the MCO in any way; it stays with the state.  

In Connecticut, when replacing the capitated MCOs with non-risk ASOs and care coordination through patient-centered medical homes, state officials considered and rejected the argument that continuing to pay the MCOs to take on the minimal risk of fluctuating costs per member per month (PMPM) was worth it. (“PMPM” is an industry standard way to measure costs and should not be confounded by fluctuations in membership.) The large pool of all Medicaid members assured the state of significant predictability for the per member costs of all of its enrollees combined. 

Medicaid populations in every state are large. If included in one risk pool, there is very limited fluctuation in PMPM costs that occurs even with a few unpredicted very expensive patients per year. Those uncommon costs are distributed across a large pool. As described earlier, fragmenting the state into multiple smaller risk pools demands larger capital reserves, which ultimately are funded by the state. 

Section E2: Managed fee for service offers states better control over their Medicaid program. States that engage with MCOs are required by federal law to provide a choice of MCOs throughout the state (except under certain circumstances in rural areas). 136 States dependent on a small number of MCOs are beholden to those MCOs, particularly if there are only two operating in parts of the state. Because of the threat – expressed or implied – during negotiations that they will depart the state if hefty annual increases are not provided, contracting with MCOs does not avoid long-term risks to the state’s budget from annual increases in the MCOs’ capitation rates. Contracting with MCOs may give a small amount of increased predictability for PMPM costs, but only for one year until rates are renegotiated. Managed fee for service eliminates this undue leverage.

Section E3: The managed fee for service model contains utilization in ways that are transparent without denying care inappropriately. In stark contrast, several independent sources find that MCOs deny care inappropriately. MCOs fail to disclose complete, accurate or timely data to demonstrate otherwise. In fact, they hide their data, rendering them effectively unaccountable for their bad acts. Without good data or any independent research to support their claims and with evidence of widespread inappropriate delays and denials of care, MCO performance should be suspect.

An OIG report found that MCOs denied 1 out of every 8 requests for prior authorization. 137 This can lead to overall wasted money and time, ultimately damage the health of the patient, promote worse health outcomes, and raise the cost of Medicaid spending.

This pattern is widely recognized by practicing physicians. In a 2024 survey by the American Medical Association, 90% of physicians reported that prior authorization leads to an increased use of healthcare through ineffective initial step-therapy treatments (69% reported), additional office visits (68% reported), emergency department visits (42% reported), and hospitalizations (29% reported). 138 Increased access to outpatient care, especially primary care, can also result in lower ER and hospital utilization, with savings that can more than offset the increase in out-patient care.

For example, in Connecticut, the shift away from MCOs to less burdensome managed fee for service brought a 14.6% increase in primary care provider enrollment, and an 11.4% increase in specialist participation, even though only primary care provider rates went up around the same time; specialists rates were unchanged. At the same time, ER usage was reduced by 15.1% and hospital inpatient readmissions were reduced by 44.4% for enrollees who engaged with the medical ASO’s care coordination and intensive discharge planning programs, respectively, while the overall enrollee hospital readmission rate dropped by 2.9% within 30 days. 139

Section E4: The blunt approach MCOs apply to utilization can lead to increased overall utilization. In states like Hawaii, the aged blind and disabled population (including most of the seriously mentally ill) was moved into private MCOs in 2009. A review of the immediate period after this demonstrated the collapse of the state’s Medicaid psychiatry network:

This collapse of the state’s Medicaid psychiatry network has important ramifications. By 2013 Hawaii documented a 30% increase in mental health ER and hospital costs compared to 2009. 141

Section E5: A far more serious problem than overutilization of healthcare services is a widespread lack of access. This is driven by profit-motivated prior authorization denials, inadequate provider networks, lack of English literacy or medical literacy, cultural resistance to seeking treatment for some kinds of medical needs, and the unaffordability of cost-sharing where it is already permitted. Each of these problems compromises health outcomes and drives up long-term expenses. 142,143

Section E6: Modest increases in utilization may well be desirable. Take for example an elderly enrollee who had a stroke and needs help with activities of daily living from a home health aide to stay in their own apartment, something which is covered under state Medicaid programs. Such a person might need five hours/day or 35 hours per week of assistance, and yet the MCO in its own judgement might only approve 7 hours/week. The MCO’s denial of those 28 hours per week could lead to an avoidable hospitalization, at greater overall expense. But even if not, the quality of life of the individual may be greatly enhanced by providing the full 35 hours needed, through not being left unable to get to bed or in soiled diapers, or not going hungry due to an inability to prepare food on their own. As we have stated earlier, it is socially desirable, and in the public interest, that this appropriate utilization be available as needed.

Section E7: The business model of managed care focuses on short-term expenses and deemphasizes the value of improving clinical care to garner long-term reductions in expense. Rather than relying upon the conflicted interests of a capitated MCO, there is a ready solution for addressing overuse in Medicaid. Connecticut again demonstrates a highly effective solution.

In 2011, when Connecticut made the decision to end its contracts with capitated MCOs, effective in January 2012, it published a Request for Proposal for non-risk administrative services organizations (ASOs) to perform the state’s prior authorization reviews. The state was thereby empowered to decide which specific services would be subject to prior authorization and the specifics of the criteria and workflow. The ASOs were charged with making these authorization determinations based on the state’s statutory definition of medical necessity 144 and some publicly-available clinical guidelines developed by the ASO in conjunction with the state. 

Unlike an MCO, the ASO has no financial incentive to grant or deny an authorization request. The ASO is simply responsible for operationalizing the parameters set by the state.

This is in contrast to other approaches to care management described earlier in this document.

Section E8: MCOs do not meaningfully coordinate the delivery of healthcare. MCOs claim that they provide quality care coordination which assures people receive appropriate care early on and thus avoid expensive hospital-based treatment which would then be at their expense. None of this is true.

MCO capitation rates often include explicit funding for care coordination, but it is in the MCO’s financial interests to perform the least amount of such work. Despite contractual language, MCO “care coordination” is often little more than reviews of expensive institutional care, such as in hospitals and rehabilitation facilities, to terminate these expensive services early to benefit their bottom lines. 

Proponents of managed care purport that capitation motivates MCOs to avoid the increased costs of preventable deteriorations in health status. MCOs, however, are predominantly concerned with their short-term financial performance. Delayed consequences of uncontrolled diabetes may not manifest until long after a patient is no longer part of that insurer’s population. The savings from improving the health status of people enrolled in the MCO would then accrue to a different insurer.

APPENDIX F: State-specific savings opportunity

A state’s savings can be determined by the amount of its Medicaid spending that runs through an MCO, the fraction of that spending that is the state’s responsibility after the federal government picks up its share (“Federal Medical Assistance Percentage” or “FMAP”), and the range of potential savings from 10% to 17% as described in Tables 1 and 2 earlier. 

Table 4 reflects savings opportunities for individual states based upon their 2023 Medicaid MCO spending 146 and their standard 2023 FMAP. 147 Although this is the most currently available comprehensive data, there have been significant changes over the subsequent three years. For example, between FY 2023 and FY 2026, the state of Missouri’s total Medicaid MCO spend increased from $5,442,500,000 to $6,560,000,000 148 while its FMAP decreased from 72% in FY 2023 to 64%. 149 The net effect for Missouri is that the upper bound of the opportunity rose from $259,000,000 displayed in Table 4 to $401,000,000 for FY 2026. A similar pattern applies across the country; the USA average FMAP in 2023 was 56.2%, but 50.0% in 2026. As the MO pattern reveals, a drop in FMAP means a larger fraction of the savings remains with the state.

Table 4 also demonstrates the Federal savings opportunity. Total Federal MCO Medicaid spending in 2023 was $ 256,605,428,133. We estimate that nationwide deprivatization of Medicaid in 2023 would have saved the federal government $ 25,660,542,813, or potentially as much as $43,622,922,782.

Table 4: Potential savings per state, FY 2023

  • Notes: 
    • “N/A” indicates data is not available as the state had no contracts with comprehensive MCOs in 2023
    • State responsibility was calculated as ((100% – FMAP) x (Total MCO spending))
  • Adjustments not included in these projections:
    • Based on 2023 data and not adjusted for medical cost inflation between 2023 and 2026, therefore underestimates the total savings opportunities.
    • Does not account for annual changes in FMAP, in particular loss of COVID bump to FMAP, therefore underestimates the savings to states and overestimates the savings by the federal government.
    • The standard FMAP is not adjusted for the 27% of the 2023 Medicaid population 150,151 who were eligible due to the ACA’s expansion of Medicaid and had a 90% FMAP, which overestimates the savings to the states and underestimates the savings to the federal government.
    • Adjusting for the expansion population FMAP would be confounded by the absence of public data comparing the state-specific pmpm costs of the expansion population within an MCO vs the non-expansion population within an MCO. It is difficult to estimate the impact of that adjustment. 

Authors

Ed Weisbart, MD; Stephen Kemble, MD; Kip Sullivan, JD; Mark S. Krasnoff, MD; Anu Dairkee, MD, JD; Nahiris M. Bahamón, MD, MPH, FAAP; Diane Archer, JD; Amelia Smith, MS and Medical Student; and Sheldon Toubman, JD

Endnotes

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      61. U.S. Department of Health and Human Services, Office of Inspector General. (2014). Access to care: Provider availability in Medicaid managed care (OEI-02-13-00660). https://oig.hhs.gov/reports/all/2014/access-to-care-provider-availability-in-medicaid-managed-care/
      62. Butala, N. M., Jiwani, K., & Bucholz, E. M. (2023). Consistency of physician data across health insurer directories. JAMA, 329(10), 841–842. https://doi.org/10.1001/jama.2023.0296
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      65. Coutinho, R. (2024, Sept 22). How one patient got trapped in a health insurance ghost network. NPR. https://perma.cc/R5TR-5D7P
      66. Busch, S. H., & Kyanko, K. A. (2020). Incorrect provider directories associated with out-of-network mental health care and outpatient surprise bills. Health Affairs, 39(6), 1012–1018. https://doi.org/10.1377/hlthaff.2019.01501 
      67. Turban, J. (2025, July 15). Ghost networks of psychiatrists hinder patients’ access to care. STAT. https://perma.cc/GBE4-GQ2L
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      69. Medicaid and CHIP Payment and Access Commission. (2021, June). Physician acceptance of new Medicaid patients: Findings from the National Electronic Health Records Survey. https://www.macpac.gov/publication/physician-acceptance-of-new-medicaid-patients-findings-from-the-national-electronic-health-records-survey/
      70. Busch, S. H., & Kyanko, K. A. (2020). Incorrect provider directories associated with out-of-network mental health care and outpatient surprise bills. Health Affairs, 39(6), 1012–1018. https://doi.org/10.1377/hlthaff.2019.01501 
      71. Gordon, S. H., Gadbois, E. A., Shield, R. R., Vivier, P. M., Ndumele, C. D., & Trivedi, A. N. (2018). Qualitative perspectives of primary care providers who treat Medicaid managed care patients. BMC Health Services Research, 18(1), 728. https://doi.org/10.1186/s12913-018-3516-9 
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      108. Duggan, M. (2004). Does contracting out increase the efficiency of government programs? Evidence from Medicaid HMOs. Journal of Public Economics, 88(12), 2549–2572. https://doi.org/10.1016/j.jpubeco.2003.08.003
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      110. In the Public Interest. (2018, March). Privatizing the VA: Lessons from privatized Medicaid in Kansas and Iowa. https://www.inthepublicinterest.org/wp-content/uploads/ITPI_PrivatizingVAMedicaid_March2018.pdf
      111. Peter Hancock, “LMH accuses KanCare contractors of systematically denying legitimate claims,” Lawrence Journal-World, December 29, 2015. http://www2.ljworld.com/news/2015/dec/29/lmh-accuses-kancare-contractors-systematically-den/.
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      113. Bisignano, T. (2016, August 2). Iowa Senate should reject privatized Medicaid. Des Moines Register. https://www.desmoinesregister.com/story/opinion/2016/08/02/tony-bisignano-iowa-senate-private-medicaid/87947626/
      114. Stopka, G. (2020, August 14). Never waste a good crisis: How human resources, networking, and training are changing during these turbulent times. Engaging Local Government Leaders (ELGL). https://elgl.org/never-waste-a-good-crisis-how-human-resources-networking-and-training-are-changing-during-these-turbulent-times/
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      117. Kaiser Family Foundation. (2025, May 9). Status of state Medicaid expansion decisions. https://www.kff.org/status-of-state-medicaid-expansion-decisions/ 
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      125. Chang, E., & Kasey, J. (2022, December 29). Focusing on health plan administrative cost. Milliman. https://www.milliman.com/en/insight/focusing-on-health-plan-administrative-cost
      126. Hogg, A. S. (2024, August 20). Is the medical loss ratio an innovation friend or foe? Christensen Institute. https://www.christenseninstitute.org/blog/is-the-medical-loss-ratio-an-innovation-friend-or-foe/
      127. Minnesota Legislature. (2025, March 21). SF 1059: Patient-Centered Care program establishment. https://www.revisor.mn.gov/bills/text.php?number=SF1059&version=0&session=ls94&session_year=2025&session_number=0
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      133. American Hospital Association. (2023, June 28). AHA comment letter on CMS’ proposed rule to ensure Medicaid services access. https://www.aha.org/lettercomment/2023-06-28-aha-comment-letter-cms-proposed-rule-ensure-medicaid-services-access 
      134. Layton, T. J., Maestas, N., Prinz, D., & Vabson, B. (2019, July). Private vs. public provision of social insurance: Evidence from Medicaid (NBER Working Paper No. 26042). https://www.nber.org/system/files/working_papers/w26042/w26042.pdf
      135. Duggan, M., Garthwaite, C., & Wang, A. Y. (2021, June). Heterogeneity in the impact of privatizing social health insurance: Evidence from California’s Medicaid program (NBER Working Paper No. 28944). https://www.nber.org/system/files/working_papers/w28944/w28944.pdf
      136. 42 C.F.R. § 438.52). See Former Medicaid Official shares troubled MCO history – CT Health Policy
      137. U.S. Department of Health and Human Services, Office of Inspector General. (2023, July 17). High rates of prior authorization denials by some plans and limited state oversight raise concerns about access to care in Medicaid managed care (OEI-09-19-00350). https://oig.hhs.gov/reports/all/2023/high-rates-of-prior-authorization-denials-by-some-plans-and-limited-state-oversight-raise-concerns-about-access-to-care-in-medicaid-managed-care/
      138. American Medical Association. (2024, August 9). Prior authorization delays care—and increases health care costs. https://www.ama-assn.org/practice-management/prior-authorization/prior-authorization-delays-care-and-increases-health-care
      139. Connecticut Department of Social Services. (n.d.). A precis of the Connecticut Medicaid program [Referencing p. 7]. https://portal.ct.gov/-/media/Departments-and-Agencies/DSS/Medicaid-Hospital-Reimbursement/precis_of_ct_medicaid_program.pdf
      140. Aaronson, A., & Withy, K. (2017). Does Hawai‘i have enough psychiatrists? Assessing mental health workforce versus demand in the Aloha State. Hawaii Journal of Medicine & Public Health, 76(3 Suppl 1), 15–17. https://pmc.ncbi.nlm.nih.gov/articles/PMC5375008/
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      142. Faiz, J., Blegen, M., Nuñez, V., Gonzalez, D., Stokes, D. C., Truong, K., Ryan, G., Briggs-Malonson, M., & Kahn, K. L. (2024). Frontline perspectives on barriers to care for patients with California Medicaid: A qualitative study. International Journal for Equity in Health, 23, 102. https://doi.org/10.1186/s12939-024-02174-8
      143. National Academies of Sciences, Engineering, and Medicine. (2023). Chapter 5: Health care access and quality. In Federal policy to advance racial, ethnic, and tribal health equity (pp. 223–268). The National Academies Press. https://doi.org/10.17226/26834
      144. Conn. Gen. Statutes § 17b-259b.
      145. Marks, S. J., Vega, V., Zhu, D., Shadowen, H., Harrell, A., Lowe, J., Mitchell, A., Barnes, A. J., & Cunningham, P. J. (2025, June 6). Challenges faced by Medicaid managed care coordinators working with members with substance use disorder. American Journal of Managed Care. https://www.ajmc.com/view/challenges-faced-by-medicaid-managed-care-coordinators-working-with-members-with-substance-use-disorder
      146. Kaiser Family Foundation. (n.d.). Total Medicaid MCO spending. KFF. https://www.kff.org/medicaid/state-indicator/total-medicaid-mco-spending/ 
      147. Kaiser Family Foundation. (n.d.). Federal matching rate and multiplier. KFF. https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/ 
      148. Missouri House of Representatives. (2025). Conference Committee Substitute for Senate Substitute for Senate Committee Substitute for House Committee Substitute for House Bill No. 11 (Sections 11.770 and 11.845). 103rd General Assembly. https://documents.house.mo.gov/billtracking/bills251/hlrbillspdf/0011H.06T.pdf
      149. Kaiser Family Foundation. (n.d.). Federal matching rate and multiplier. KFF. https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/ 
      150. Harker, L., & Sharer, B. (2024, June 14). Medicaid expansion: Frequently asked questions. Center on Budget and Policy Priorities. https://www.cbpp.org/research/health/medicaid-expansion-frequently-asked-questions-0 
      151. Kaiser Family Foundation. (2025, July 28). Medicaid enrollment and unwinding tracker. https://www.kff.org/medicaid/medicaid-enrollment-and-unwinding-tracker/#93469f01-80b8-4f2a-b58e-f00496dff23f

PNHP Reports and Proposals

PNHP’s North Star is the Physicians’ Proposal for Single-Payer Health Care Reform. If you haven’t read the Physicians’ Proposal, please do so today—and share it with your colleagues!

In addition to this bedrock vision, PNHP has published reports and proposals on a range of health-related topics. Please see below for a chronological list, as well as a series of statements on timely health justice issues.

PNHP Reports and Proposals

No Real Choices: How Medicare Advantage Fails Seniors of Color
By Physicians for a National Health Program
Originally published Oct. 15, 2025
Click HERE to read the report

Removing the Middlemen from Medicaid: A Blueprint for Better Care and Lower Costs
By Physicians for a National Health Program
Originally published Sept. 2, 2025
Click HERE to read the report

Taking Advantage: How Corporate Health Insurers Harm America’s Seniors
By Physicians for a National Health Program
Originally published May 23, 2024
Click HERE to read the report

Our Payments, Their Profits: Quantifying Overpayments in the Medicare Advantage Program
By Physicians for a National Health Program
Originally published Oct. 4, 2023
Click HERE to read the report

Eight Needed Steps in the Fight Against COVID-19
By Adam Gaffney, M.D., M.P.H.
Originally published in Boston Review, April 3, 2020
Click HERE to access the proposal and additional materials

Healing an ailing pharmaceutical system: Prescription for reform for U.S. and Canada
By Adam Gaffney, M.D., M.P.H.; Joel Lexchin, M.D.; and the US, Canadian Pharmaceutical Policy Reform Working Group
Originally published in The BMJ, May 17, 2018
Click HERE to access the proposal and supplemental materials

A Better-Quality Alternative: Single-Payer National Health System Reform
By Gordon D. Schiff, M.D.; Andrew B. Bindman, M.D.; and Troyen A. Brennan, M.D., J.D., M.P.H.; for the PNHP Quality of Care Working Group
Originally published in JAMA, Sept. 14, 1994
Click HERE to read the proposal

A National Long-term Care Program for the United States: A Caring Vision
By Charlene Harrington, R.N., Ph.D.; Christine Cassel, M.D.; Carroll L. Estes, Ph.D.; Steffie Woolhandler, M.D., M.P.H.; David U. Himmelstein, M.D.; and the Working Group on Long-term Care Program Design
Originally published in JAMA, Dec. 4, 1991
Click HERE to read the proposal

Liberal Benefits, Conservative Spending
By Kevin Grumbach, M.D.; Thomas Bodenheimer, M.D., M.P.H.; David U. Himmelstein, M.D.; and Steffie Woolhandler, M.D., M.P.H.
Originally published in JAMA, May 15, 1991
Click HERE to read the proposal

PNHP Statements

Consensus Statement on Expanding Prior Authorization in Traditional Medicare
Click HERE to read our statement—originally issued Aug. 5, 2025

CMS should terminate the Medicare Advantage program
Click HERE to read our statement—originally issued Aug. 25, 2022

Abortion care is fundamental health care
Click HERE to read our statement—originally issued June 24, 2022

Police violence and racism are public health emergencies
Click HERE to read our statement—originally issued June 2, 2020

Board of Directors statements on diversity, reproductive rights, and mifepristone
Click HERE to read these statements—scroll to the bottom of the page

2025 Annual Meeting

Building Community, Building Power

Register for the conference HERE!

Join hundreds of PNHP and SNaHP members as we gather in Washington, D.C. to build community with like-minded colleagues and to build power in the nation’s capital.

NOTE: to accommodate our advocacy day on Monday, Nov. 3, this year’s conference has a new structure and days/times. Please be aware of these changes when making your travel arrangements.

PNHP Annual Meeting & SNaHP Summit

Detailed conference schedule available HERE

Saturday, Nov. 1

  • SNaHP Summit (students only), 9:00 am – 2:00 pm
  • PNHP Annual Meeting, 2:00 pm – 5:00 pm
  • Reception, Dinner & Keynote, 5:00 pm – 9:00 pm

Sunday, Nov. 2

  • PNHP Annual Meeting, 9:00 am – 12:00 pm
  • Lunch, 12:00 pm – 1:15 pm
  • Small group meetings and advocacy day preparations, 1:30 pm – 5:00 pm

Monday, Nov. 3

  • Advocacy Day & Rally at the U.S. Capitol, 8:00 am – 2:00 pm

Location & Hotel

The SNaHP Summit and PNHP Annual Meeting will be held at American University’s Washington College of Law, located at 4300 Nebraska Ave NW, Washington, DC 20016. The location is accessible via Metro (AU-Tenleytown red line).

Sleeping rooms are available at the Embassy Suites Washington DC Chevy Chase Pavilion, 4300 Military Rd NW, Washington, DC 20015, for $179/night for a king suite or $189/night for a double suite. The location is accessible via Metro (Friendship Heights red line, 1 stop from the meeting venue).

  • Reservations may be made online here.
  • If you would like to book a room with arrival prior to Oct. 31 or departure after Nov. 3, please contact Matt Petty at matt@pnhp.org.

Sleeping room reservations must be made by Friday, Oct. 10.

Speakers

Keynote: Uché Blackstock, MD, founder and CEO of Advancing Health Equity, and former associate professor in the Department of Emergency Medicine and former faculty director for recruitment, retention, and inclusion in the Office of Diversity Affairs at NYU School of Medicine

Meeting Chair: Diljeet Singh, MD, DrPH, PNHP president, women’s health advocate, and integrative gynecologic oncologist

Welcome (Sunday): Robert Weissman, JD, Co-President, Public Citizen

Health Policy Update (Saturday): Adam Gaffney, MD, MPH, past president of PNHP, pulmonologist at Cambridge Health Alliance, and assistant professor of medicine at Harvard Medical School; Gita Lakshminarayanan, MD student at the University of Florida College of Medicine; and Amelia Smith, MD student at the University of Illinois College of Medicine at Chicago

Building Community, Building Power Panel Discussion (Saturday): Jamila Headley, PhD, Executive Director, Be A Hero; Rob Davidson, MD, MPH, emergency physician and Executive Director, Committee to Protect Health Care; Hayden Rooke-Ley, JD, Senior Fellow for Healthcare, American Economic Liberties Project and Senior Fellow, Brown University School of Public Health; and Philip Verhoef, MD, PhD, pediatric and adult intensivist and immediate past president, PNHP (moderator)

PNHP’s Medicare Advantage Equity Report Panel Discussion (Sunday): Donald Moore, MD, MPH, retired general medicine physician and board member, PNHP NY Metro; Claudia Fegan, MD, PNHP national coordinator and former Chief Medical Officer, Cook County Health; Rachel Madley, PhD, Director of Policy and Advocacy at the Center for Health and Democracy, former Health Policy Advisor to Rep. Pramila Jayapal, and former SNaHP Executive Board Member; Belinda McIntosh, MD, psychiatrist and national board member, PNHP (presenter and panelist); and Ed Weisbart, MD, retired family physician and national board secretary, PNHP (moderator)

Sounding the Alarm on Physician Moral Injury (Sunday): Anand Habib, MD, MPhil, assistant professor and attending physician in the Division of Hospital Medicine at the University of California San Francisco, and moral injury researcher, PNHP

This conference will not be livestreamed in its entirety. Recordings of select sessions will be made available after the meeting.

Student and Resident Scholarships

Scholarships are available to students and residents to cover a portion of the cost of travel and lodging. More information will be available this summer.

PNHP members and the public can support PNHP’s student outreach programs by making a GIFT to the Nicholas Skala Student Fund.

Previous Annual Meetings

Click HERE to access archival material from last year’s Annual Meeting in Chicago. Click HERE to view photos from the conference.

Attending the 2025 PNHP Annual Meeting and SNaHP Summit is entirely voluntary and requires attendees to abide by any applicable rules of conduct, or local or state laws, that may be announced at any time. Attendees acknowledge the highly contagious and evolving nature of Covid-19 and voluntarily assume the risk of exposure to, or infection with, the virus by attending the Meeting, and understand that such exposure or infection may result in personal injury, illness, disability, and/or death. Attendees release and agree not to sue any persons or entities responsible for coordinating or organizing the PNHP Annual Meeting and SNaHP Summit in the event that they contract Covid-19. Attendees agree to comply with all Covid-related procedures that may be implemented at the Meeting, including mask-wearing.

Member Interest Groups (MIGs)

Welcome to the PNHP Member Interest Groups (MIGs) Hub.

While PNHP has traditionally organized through city- and state-based chapters, we’ve recently expanded to include specialty-focused Member Interest Groups (MIGs). These groups bring together members around specific medical specialties or social justice issues to deepen our advocacy and organizing efforts.

If you’re interested in joining one of our current MIGs—or starting a new one—you’re in the right place.

Learn more about our existing MIGs

Infectious Disease:

Pediatrics:

Psychiatry:

Reproductive Justice:

Start your own MIG

Don’t see your medical specialty or advocacy interests represented above? Email PNHP national organizer Rebecca Delay at rebecca@pnhp.org and we’ll help you connect with like-minded members!

The Medicare for All Act of 2025

On April 29, 2025, Rep. Pramila Jayapal, Rep. Debbie Dingell, and Sen. Bernie Sanders introduced the Medicare for All Act in the U.S. House (H.R. 3069) and U.S. Senate (S. 1506). These landmark pieces of legislation would finally establish a single-payer national health program in the United States.

PNHP welcomes these bills and urges Congress to move quickly to guarantee universal coverage, comprehensive benefits, and zero out-of-pocket costs for all U.S. residents.

Overview of the Medicare for All Act

Activism on the Medicare for All Act

  • Send an email to your legislators and and ask them to co-sponsor the bill.
  • Call your representative and senators at (202) 224-3121 and ask them to co-sponsor.
  • Schedule in-person meetings with your legislators—or with health policy staffers at their district offices; this is a crucial part of building powerful relationships with your representatives.
  • If your legislator is already a co-sponsor, thank them for their support and ask them to be even more public in their single-payer advocacy. See the Congressional website for a list of current co-sponsors in the House and Senate.
  • Seek out allied organizations, both locally and nationally, to expand the reach of your activism. Review this list of over 100 organizations that have endorsed Medicare for All.
  • Write an op-ed or letter to the editor supporting the Medicare for All Act.

Introductory press conference

Organizing for Medicare for All virtual rally

Social media graphics

Original posts on Instagram, Bluesky, and Facebook

Original posts on Instagram, Bluesky, and Facebook

Original posts on Instagram, Bluesky, and Facebook

Original posts on Instagram, Bluesky, and Facebook

Original posts on Instagram, Bluesky, and Facebook

Original posts on Instagram, Bluesky, and Facebook

PNHP Newsletter: Spring 2025

Table of contents

Click the links below to jump to different sections of the newsletter. To view a PDF version of the shorter print edition of the newsletter, click HERE.

If you wish to support PNHP’s outreach and education efforts with a financial contribution, click HERE.

If you have feedback about the newsletter, email info@pnhp.org.

PNHP News and Tools for Advocates

Save the Date for our Annual Meeting in Washington, D.C.

Data Update: Health Care Crisis by the Numbers

PNHP Chapter Reports

SNaHP Chapter Reports

Responding to the UnitedHealthcare CEO Murder

PNHP in the News

PNHP News and Tools for Advocates

Welcome letter from PNHP’s new president, Dr. Diljeet Singh

PNHP president Dr. Diljeet K. Singh

With appalling health outcomes, deplorable health inequities, and staggering rates of medical bankruptcy, we have long known American health care has been broken by an unregulated, profit-driven health insurance industry that must be dismantled. Since taking office, the Trump administration has taken us in the opposite direction. They have begun the destruction of our medical research and public health infrastructure while simultaneously threatening the foundations of traditional Medicare and Medicaid.

At PNHP, we know the fight for health justice is a long one—but we take strength from our growing coalition, and from members like you, who continue to speak out and organize for a truly equitable health care system. We have hope and deep gratitude for all our members engaged with the movement and working to support the well-being of all.

We are especially proud to congratulate our graduating SNaHP (soon to be PNHP!) members who have matched in various specialties across the country. In them, we see the future of our profession: bold, principled, and committed to transforming the system. We are grateful for their co-leadership in our organizing efforts and are excited to support them through their residencies and fellowships.

As we continue building power within our movement, we want to share a few highlights from what we’ve been working on this year: Our Moral Injury Project continues to shine a light on how profit-driven “care” harms both patients and health professionals, our Equity Project is exploring how privatized Medicare plans exacerbate racial inequities, and our legislative advocacy has been in full force, with PNHP members organizing 45 legislative visits, calling for action against corporate abuse, overpayments, and care denials.

Our work does not happen in isolation—we are constantly collaborating with allied organizations to build collective power and push for systemic change. One powerful example was the recent Dr. Oz “shadow hearing,” which we co-hosted with Social Security Works and which was co-sponsored by 12 other organizations. This event spotlighted the devastating harms of corporate health care and amplified the voices of patients, providers, and advocates demanding a better system.

Working together makes us stronger—and brings us closer to the just and equitable health care system we all deserve. That spirit of collaboration and collective action will be front and center at PNHP’s Annual Meeting in Washington, D.C. on Nov. 1-3. We’ll dig deeper into our campaigns to challenge Medicare privatization and strategize together on how to grow our movement in the year ahead.

Thank you so much for your membership, your engagement, and your strength during these politically turbulent times. We are proud to be in this movement with you. Please reach out if I can help support you in any way.

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“Shadow Hearing” for Dr. Mehmet Oz

On Friday, March 14, at 9:00 a.m. Eastern—one hour before Mehmet Oz’s official hearing in Washington, D.C.—PNHP hosted a virtual “shadow hearing” to expose the truth about his plans for CMS: Medicaid cuts, Medicare privatization, and the devastating consequences of Medicare Advantage (MA). This event, which was co-sponsored by 13 allied health justice organizations, featured 11 speakers who shared firsthand experiences of the harm caused by privatized health care, whether as patients struggling to access care or as providers fighting insurance denials.

Social Security Works executive director Alex Lawson and PNHP board member Dr. Alankrita Olson joined us live from outside the hearing room in D.C., offering real-time updates on the scene. Together, we worked to counter the pro-privatization narrative pushed by Dr. Oz, whose self-serving perspective disregards the health and well-being of the American people.

The speakers underscored the dangerous reality of so-called “Advantage” plans, which systematically deny care to boost corporate profits, leaving patients in medical and financial distress. Stories highlighted insurers’ routine delays and denials, the administrative burdens placed on providers, and the real-life consequences for those trapped in a system designed to prioritize profits over patients.

This event served as a direct call to action, urging Americans to contact their legislators and demand that they reject policies that would further entrench the privatization of our public health programs.

To learn more about actions you can take today, visit pnhp.org/Oz.

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PNHP’s Moral Injury Project receives IRB approval

The PNHP Moral Injury Project has officially received Institutional Review Board (IRB) approval, and we are moving forward with full-scale research and outreach efforts! Since January 2025, our working group of 25 PNHP members and SNaHP students has been meeting regularly, organizing into four dedicated teams to advance different aspects of the project.

The Presentations Team is focused on developing and delivering presentations on moral injury at PNHP chapter meetings, medical society events, and residency programs to raise awareness and spark discussion. The Materials Team is creating essential outreach materials, including an FAQ sheet, flyers, an information sheet, and an outreach toolkit, equipping members with the necessary resources to educate and engage others. (All of these materials can be found at pnhp.org/MoralInjury.) The Research Team is exploring nontraditional research strategies, such as social media outreach, to expand the project’s visibility and impact. Finally, the Network Outreach Team is working to establish connections with medical societies and residency programs to distribute our survey and link the Presentations Team with opportunities to present.

We are also advancing into the second phase of our interviews, where we are designing guides and structuring physician interviews to gather firsthand accounts of moral injury in U.S. health care. Our first round of physician interviews are anticipated to be conducted by the end of April 2025.

If you would like to be involved in our Moral Injury Working Group, please contact Rebecca Delay at rebecca@pnhp.org. Stay tuned for further updates as we expand our outreach, research, and advocacy efforts!

PNHP’s Moral Injury Project is funded with generous support from the Robert Wood Johnson Foundation.

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Medicare “Advantage” report to measure racial inequities in MA

PNHP’s Medicare Advantage Equity Project is well underway, focusing on developing a comprehensive report analyzing the impact of MA on racial health inequities. This project seeks to examine and debunk insurers’ claims that their privatized Medicare plans promote health equity, equipping legislators with the information to challenge misleading narratives used to justify MA’s expansion. This project will strengthen PNHP’s advocacy by ensuring policymakers have access to credible research and critical stakeholder insights that expose the harm that corporate insurers inflict on marginalized communities.

To guide this project, we have established two advisory bodies. An internal advisory committee of eight PNHP and SNaHP members is helping shape the research process and ensure validity in our analysis. Additionally, an external steering committee of seven health equity experts from various organizations is advising on research practices, guiding our focus areas, and structuring a framework to align with the project’s mission. Their expertise ensures that our research remains thorough, relevant, and impactful.

So far, we have conducted a literature review exploring existing research on health outcomes for marginalized communities with heavy enrollment in MA plans. This review has helped us identify gaps in current research and begin structuring the framework for our report and the next phase of research. Moving forward, we are working to build upon these findings to present a clear, evidence-based critique of insurers’ equity claims while developing accessible materials for legislators and policymakers. As we continue, our goal remains clear: to expose how MA exacerbates racial health inequities and provide lawmakers with the resources needed to push back against privatization efforts that disproportionately harm vulnerable communities.

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Bringing our fight to Washington

Rep. Pramila Jayapal meets with PNHP and SNaHP members at our Annual Meeting in Chicago on Nov. 16, 2024.

On March 27, Rep. Pramila Jayapal sent a letter to the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS), urging them to take action to curb waste, abuse, and patient harm in Medicare Advantage (MA).

The letter calls for eliminating waste and abuse by improving risk adjustment calculations in the proposed 2026 Medicare Advantage Rate Notice, strictly enforcing overpayment regulations outlined in the 2025 Medicare Physician Fee Schedule rule, and strengthening enforcement against MA insurers that illegally deny care.The letter also calls for reforms to promote health equity by addressing disparities in care outcomes and improving data-sharing mechanisms to help enrollees make informed choices.

PNHP has been actively engaging legislators on this issue, having conducted 45 legislative visits to urge lawmakers to sign onto this letter. Our efforts built on last year’s success, when PNHP’s advocacy helped CMS stand firm against aggressive industry opposition to a more reasonable 2024 MA rate hike. By mobilizing our network to support actuarially sound rate adjustments, we helped counter the immense lobbying power of corporate insurers.

While the political landscape may be more challenging in 2025, PNHP’s advocacy has proven highly effective, and continued mobilization is essential to holding CMS and HHS accountable.  Our members are off to an impressive start this year; Rep. Jayapal’s pro-Medicare letter was signed by 78 members of the U.S. House of Representatives, compared to 65 who signed a similar letter in 2024.

Looking ahead, we are anticipating the introduction of the Medicare for All Act in April. Reps. Jayapal and Dingell will be sponsoring the House bill while Sen. Bernie Sanders sponsors the Senate bill. As with previous versions, this legislation would establish a single-payer national health program, removing the profit-driven middlemen that exploit both patients and providers.

PNHP and our allies are already working to urge legislators to sign on as co-sponsors once the bill is introduced. We encourage all PNHP members and supporters to join this effort by contacting their legislators after the bill’s launch and either thanking them for co-sponsoring or urging them to get on board. As we continue to expose the failures of privatized health care and fight back against industry influence, Medicare for All remains the ultimate solution to our nation’s health care crisis. Our advocacy has already made a significant impact, and with strong grassroots mobilization, we can continue to push for fundamental reform.

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Save the Date for our Annual Meeting in Washington, D.C.

PNHP’s 2025 Annual Meeting is set for November 1-3 in Washington, D.C., bringing together physicians, medical students, and health care advocates for a powerful weekend of education and action! The weekend will kick off with the SNaHP Summit on Saturday morning, providing medical students with a dedicated space to strategize, connect, and strengthen their organizing efforts.

The PNHP Annual Meeting will begin Saturday afternoon and continue through Monday, featuring panels, discussions, and opportunities to deepen our advocacy for single-payer health care. The event will culminate in a Lobby Day and Rally at the Capitol on Monday, November 3, where members will demand action to protect and expand Medicare while pushing for a single-payer system.

Stay tuned for more details on programming, speakers, and registration!

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Data Update: Health Care Crisis by the Numbers

Corporate Profiteering

OIG: Insurers Should Pay Feds Millions: A new watchdog audit found that Humana and CVS Medicare Advantage plans owe the federal government $11 million in overpayments. The HHS Office of the Inspector General (OIG) audited medical claims from 2017-2018 and determined that 202 out of 240 reviewed diagnostic codes from Humana were unsupported by medical records, leading to an estimated $6.8 million in overpayments. Similarly, HealthAssurance Pennsylvania, a CVS subsidiary, had 222 out of 269 diagnostic codes lacking proper documentation, resulting in $657,744 in overpayments. The audit will be sent to CMS officials, who will decide whether to recoup the overpayments. The findings highlight ongoing scrutiny of Medicare Advantage plans and concerns that private insurers are overpaid by CMS. “Feds seek $11M refund from Humana, CVS,” Politico, September 26, 2024.

Report Reveals Billions in Excess Medicare Payments: A new inspector general’s report found that private Medicare insurers received approximately $4.2 billion in extra federal payments in 2023 for diagnoses obtained through company-initiated home visits—many of which did not lead to treatment. These diagnoses, including potentially inaccurate ones, triggered higher payments because Medicare Advantage insurers receive increased reimbursements when patients are classified with costly conditions. The findings raise concerns about how home visits are used to inflate payments without providing meaningful medical care. “Medicare Paid Insurers Billions for Questionable Home Diagnoses, Watchdog Finds,” The Wall Street Journal, October 24, 2024.

Medicare Advantage Denied 1.5 Million Claims in a Single Year, Leaving Patients Vulnerable: In 2019 alone, Medicare Advantage insurers denied 1.5 million claims—18% of all payments—even when they met Medicare coverage rules. These denials force enrollees to either forgo needed medical care or pay out-of-pocket. In 2024, the government will give private insurers an additional $64 billion to cover “free” benefits like dental and vision, yet insurers refuse to disclose how much they actually spend on patient care. A study found that only 11% of enrollees used dental benefits, while another found that a quarter never used any of the advertised perks. Meanwhile, major hospitals like Scripps Health and Mayo Clinic are rejecting Medicare Advantage patients due to unpaid bills. “The Medicare Advantage Trap: What They Don’t Tell You,” The Hartmann Report, October 5, 2024.

Private Medicare Plans Collected $7.5 Billion in Questionable Payments: A new report from the HHS Office of Inspector General (OIG) reveals that private Medicare Advantage plans received $7.5 billion in enhanced payments in 2023 based on potentially suspect patient diagnoses. Most of these risk-adjusted payments came from in-home “health risk assessments” and chart reviews—evaluations often conducted by individuals with no direct involvement in a patient’s care. UnitedHealth Group alone collected over $3.7 billion from these assessments, while Humana received nearly $1.71 billion and Cigna Group took in $237 million. The OIG is calling for greater oversight of these practices to ensure Medicare Advantage insurers are not inflating payments without providing necessary follow-up care. “Watchdog Flags $7.5 Billion Paid to Private Medicare Plans,” Bloomberg Law, October 24, 2024.

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Barriers to Care

80% of Mental Health Providers in Medicare Advantage Directories Are Unreachable: A Senate Finance Committee investigation found that Medicare Advantage (MA) plan directories are riddled with “ghost networks,” where listed mental health providers are often inaccurate, unavailable, or out-of-network. In a secret shopper study across six states, staff contacted 120 listed providers and found that 33% had incorrect or non-working numbers, while appointments could only be scheduled 18% of the time. In some states, the success rate was as low as 0%. The report highlights the serious barriers individuals face when seeking mental health care and calls on CMS to strengthen oversight of MA provider directories. It also urges Congress to mandate stricter accuracy requirements, transparency measures, and financial penalties for non-compliance. “Majority Study Findings: Medicare Advantage Plan Directories Haunted by Ghost Networks,” Senate Finance Committee, May 3, 2023.

Medicare Advantage Insurers Deny Critical Post-Acute Care at Alarming Rates: A U.S. Senate investigation found that UnitedHealthcare, Humana, and CVS—covering nearly 60% of Medicare Advantage enrollees—used prior authorization to deny critical post-acute care at disproportionately high rates. In 2022, UnitedHealthcare and CVS denied prior authorization for post-acute care at three times their overall denial rates, while Humana’s denial rate for such care was 16 times higher than its overall rate. UnitedHealthcare’s denials for skilled nursing facilities surged ninefold between 2019 and 2022, while CVS “saved” over $660 million in a single year by denying inpatient care requests. Internal documents show insurers used automation and predictive algorithms to increase denial rates, prioritizing financial savings over medical necessity. “Refusal of Recovery: How Medicare Advantage Insurers Have Denied Patients Access to Post-Acute Care,” U.S. Senate Permanent Subcommittee on Investigations, October 17, 2024.

Prior Authorization Delays Linked to Severe Patient Harm, Physicians Report: A 2024 AMA survey found that 29% of physicians reported prior authorization (PA) has led to a serious adverse event for a patient in their care. Additionally, 23% said PA resulted in a patient’s hospitalization, 18% reported it caused a life-threatening event or required intervention to prevent permanent harm, and 8% stated that PA led to disability, permanent bodily damage, congenital anomalies, or even death. The findings highlight the significant risks PA policies pose to patient safety and the urgent need for reform. “2024 AMA Prior Authorization Physician Survey,” AMA, June 18, 2024.

Medicare Advantage Delays and Denials Worsen Rural Health Care Challenges: A report from the American Hospital Association found that 81% of rural clinicians say insurer requirements under Medicare Advantage (MA) reduce the quality of care, while MA patients experience 9.6% longer hospital stays before receiving post-acute care compared to traditional Medicare patients. Administrative burdens have also intensified, with nearly 80% of rural clinicians reporting increased paperwork over the past five years, and 86% stating that these challenges negatively affect patient outcomes. Delayed or denied MA payments further strain rural hospitals’ finances, threatening access to care in underserved areas. “The Growing Impact of Medicare Advantage on Rural Hospitals Across America,” American Hospital Association, February 2025.

Private Insurance and Medicare Advantage Have Higher Claim Denial Rates Than Traditional Medicare: An analysis found that 21% of people with employer-sponsored insurance and 20% of those with marketplace insurance experienced denied claims, compared to 10% of Medicare beneficiaries and 12% of Medicaid enrollees. A separate 2024 survey of hospitals and post-acute care providers by Premier, Inc. found that nearly 15% of medical claims submitted to private insurers were initially denied, with Medicare Advantage having a higher denial rate of 15.7%. “Breaking Down Claim Denial Rates by Healthcare Payer,” TechTarget, January 9, 2025.

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Pharma

Eli Lilly CEO Took Home $114 Million in 2024 Amid Record Profits and Perks: Eli Lilly CEO Dave Ricks made $114 million last year, a rare nine-figure payout for a health care executive, according to a new proxy statement. The company also reimbursed Ricks and two other executives for $186,000 in expenses related to a “global executive leadership meeting” held in Paris alongside the 2024 Olympics. Lilly’s soaring profits—$10.6 billion in 2024, more than double the previous year—were driven by its blockbuster GLP-1 drugs, Mounjaro and Zepbound. With investor enthusiasm for next-generation treatments, Lilly has become the world’s wealthiest health care company. “Lilly CEO Got a Big Payday (and an Olympics Treat),” STAT, March 12, 2025.

Pharmaceutical Companies Have Already Raised Prices on Over 800 Drugs in 2025: Drugmakers have increased the prices of more than 800 brand-name prescription drugs this year, with a median hike of 4%. Leadiant Pharmaceuticals raised prices significantly: by 15% to $149 per pill for Matulane, a Hodgkin disease treatment, and by 20% (to $2,597) for Cystaran, eye drops for cystinosis. The total number of price hikes has risen sharply from 140 announced in late December, with more expected by the end of 2025. “Big Pharma Has Already Raised the Prices of Hundreds of Drugs This Year,” Quartz, January 28, 2025.

Nearly 72 Million Americans Skipped Needed Care Due to Cost in 2024: The West Health-Gallup 2024 Survey on Aging in America found that an estimated 72.2 million adults—nearly one in three—did not seek necessary health care in the past three months (May-July 2024) due to cost, including 8.1 million Americans aged 65 and older. Additionally, nearly one-third (31%) of respondents expressed concern about affording prescription drugs in the next 12 months, a sharp rise from 25% in 2022. The findings highlight a worsening affordability crisis in the U.S. health care system. “Americans’ Ability to Afford Healthcare Hits New Low in 2024,” News Medical Life Sciences, July 17, 2024.

Majority of Congress Receives Significant Contributions from Pharmaceutical Industry: An analysis of OpenSecrets data found that most U.S. lawmakers receive substantial financial contributions from pharmaceutical and health product companies. On average, House Republicans received $45,000 and House Democrats $47,000, while Senate Republicans averaged $50,000 and Senate Democrats $69,000 in the 2024 election cycle. At least 72 of 100 U.S. senators received at least $10,000 from pharmaceutical PACs or employees, with 12 senators surpassing $100,000—including seven Democrats and five Republicans. The findings highlight the deep financial ties between lawmakers and the pharmaceutical industry. “How Many Members of Congress Receive Money from Pharmaceutical Company PACs?” DeseretNews, January 31, 2025.

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Health Inequities

Medicare Advantage Networks Restrict Access to Racially Concordant Physicians: A Health Affairs report found that Medicare Advantage (MA) network limitations exacerbate racial and ethnic disparities by restricting access to Black and Hispanic physicians, who are known to improve preventive care use among these populations. Black and Hispanic physicians are underrepresented in MA networks compared to White physicians (43.2% and 44.0% vs. 51.1%), and many Black and Hispanic beneficiaries lack any in-network doctors of their race. In 41.3% of counties, there are no Black physicians in MA networks, while 47.2% of counties lack Hispanic physicians. These restrictions limit culturally competent care, reinforcing barriers to preventive services and worsening health disparities for MA enrollees. “Medicare Advantage Networks Include Few Black or Hispanic Physicians, Making Concordant Care Inaccessible for Many,” Health Affairs, January 2025.

MA Enrollees Report Widespread Unfair Treatment in Health Care: A Health Affairs study of 1,863 Medicare Advantage (MA) enrollees from 21 plans found that 9% reported experiencing unfair treatment in a health care setting, with the most common reasons being health condition (6%), disability (3%), and age (2%). Among those reporting unfair treatment, 40% cited multiple forms of discrimination. Enrollees qualifying for Medicare via disability were more likely to report unfair treatment based on disability, age, income, race and ethnicity, sex, sexual orientation, and gender identity. “Medicare Advantage Enrollees’ Reports of Unfair Treatment During Health Care Encounters,” Health Affairs, May 29, 2024.

Fewer High-Quality Medicare Advantage Plans Available in Socially Vulnerable Areas: A study found that markets with greater unmet social needs—measured by higher Social Vulnerability Index (SVI) scores—have fewer high-quality Medicare Advantage (MA) plans. The most vulnerable markets had 1.5 fewer MA plans overall and 1.1 fewer plans rated 4 stars or higher compared to the least vulnerable markets. This disparity was most pronounced in the southern U.S., where a higher proportion of Black/African American populations reside. “Association of Social Vulnerability and Access to Higher Quality Medicare Advantage Plans,” Journal of General Internal Medicine, December 20, 2024.

Medicare Advantage Enrollment Growth Among Racial Minorities Driven by Financial Barriers, Not Equity: While industry apologists point to the increasing enrollment of racial and ethnic minorities in Medicare Advantage (MA) as a sign of greater equity, research suggests this trend is largely driven by financial necessity rather than improved access to quality care. A study in The American Journal of Managed Care found that 40% of Black and Hispanic Medicare beneficiaries are near-poor, earning between 101% and 250% of the federal poverty level (FPL). These individuals do not qualify for Medicare supplemental insurance but often struggle to afford necessary care. Compared to White beneficiaries, Black and Hispanic enrollees are less likely to have savings or supplemental coverage, making MA’s lower cost-sharing and additional benefits an economic relief rather than a fundamental improvement in care access. “Racial/Ethnic Disparities in Cost-Related Barriers to Care Among Near-Poor Beneficiaries in Medicare Advantage vs Traditional Medicare,” The American Journal of Managed Care, October 23, 2024. 

Medicare Advantage Attracts Low-Income Enrollees with Limited Benefits While Restricting Care: Claims that Medicare Advantage (MA) improves equity obscure the reality that many low-income beneficiaries choose these plans out of financial necessity rather than for superior care. A JAMA Health Forum study found that Black beneficiaries were 9.0 percentage points more likely to enroll in a plan with any dental benefit and 11.2 percentage points more likely to choose a comprehensive dental plan than White beneficiaries. However, this trend reflects cost-driven decision-making rather than expanded access to quality care. MA plans use zero-premium options and supplemental benefits to attract enrollees while simultaneously restricting provider networks and specialized care, ultimately reinforcing disparities rather than addressing them. “Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits,” JAMA Health Forum, January 12, 2024.

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Burnout

Medicare Advantage Prior Authorization Delays Harm Patients, Fuel Burnout: A 2024 AMA survey found that over 90% of physicians, including those treating nursing home patients, reported that prior authorization (PA) delays have caused significant patient harm. For 24% of these doctors, the delays resulted in hospitalization, permanent disability, or death. Physicians spend an average of 12 hours per week handling 43 PA requests, contributing to widespread burnout; 95% cite PA as a reason for stress, and one in five are considering leaving medicine within two years. “‘Broken System’ of Medicare Advantage Prior Authorizations Leads to Nursing Home, Hospital Woes,” Skilled Nursing News, October 29, 2024.

Physician Burnout Continues to Drive Early Retirements and Exits in 2024: A MGMA Stat poll found that 27% of medical groups had a physician leave or retire early in 2024 due to burnout, while 41% reported that burnout worsened this year. Meanwhile, 45% said burnout levels remained the same as last year. The poll, based on 449 responses, highlights the persistent impact of burnout on the health care workforce, even as unexpected turnover stabilizes. “Physician Burnout Still a Major Factor Even as Unexpected Turnover Eases,” MGMA, September 4, 2024.

Higher Nurse Turnover Intentions Linked to Increased Patient Mortality: A multinational study analyzing data from 1,046 nurses across 15 public hospitals in Italy found a direct correlation between nurse intentions to quit and patient mortality. The study focused on surgical patients aged 50 and older who had hospital stays of at least two days. Researchers found that for every 10% increase in nurses intending to leave their jobs, inpatient hospital mortality rose by 14%. “Study Links Nurse Intention to Quit with Patient Mortality,” Health Policy, March 16, 2024.

Emergency Medicine Tops List of Most Burned-Out Specialties in 2024: A Healthgrades survey of 9,226 physicians across 26 specialties found that emergency medicine had the highest burnout rate at 63%, followed by obstetrics/gynecology (53%), oncology (53%), and pediatrics (51%). 42% of physicians said they had been burned out for over two years, and 16% considered leaving medicine due to burnout. Key contributors included excessive bureaucratic tasks, long work hours, lack of respect from colleagues, and inadequate compensation. “2024’s Most and Least Burned Out Physicians by Specialty,” Healthgrades, April 16, 2024.

Nearly Half of Physicians Report Burnout, While Depression Rates Remain Stagnant: A Medscape survey found that 47% of physicians are currently experiencing burnout, while 24% report depression—a rate that has remained unchanged since 2020. The findings reveal ongoing challenges in physician mental health, underscoring the need for workplace reforms and support systems. “‘If Boundaries Are Set, It Is Possible’: Medscape Physician Mental Health & Well-Being Report 2025,” Medscape, January 31, 2025.

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Corporate Health Insurance

Humana Faces Billions in Losses After Medicare Advantage Ratings Drop: Humana, one of the largest Medicare Advantage providers, saw its stock plunge to a 15-year low after the federal government downgraded the rating for one of its major plans. In a filing to the SEC, Humana disclosed that only 1.6 million members—about 25% of its total—will be enrolled in Medicare Advantage plans rated four stars or higher in 2025, a sharp drop from 94% this year. CMS assigns star ratings based on factors like provider performance and plan administration, with higher ratings leading to lucrative government bonuses. A key Humana plan covering 45% of its Medicare Advantage members is expected to drop from 4.5 to 3.5 stars, potentially costing the company nearly $3 billion in 2026 bonus payments. Humana is appealing the rating but acknowledged its impact on future earnings. “Medicare Advantage Giant Humana Reels After Ratings Cut,” The Washington Post, October 2 2024.

UnitedHealth Faces Stock Decline Amid Medicare Billing Investigation and Industry Scrutiny: UnitedHealth’s Medicare Advantage division, the largest in the country with over 7.8 million enrollees, is under investigation by the U.S. Department of Justice for potential civil fraud related to its Medicare billing practices. When this story broke, it sent UnitedHealth’s stock plummeting more than 10% in pre-market trading, dropping over $52 to below $447 per share. Other Medicare Advantage insurers, including Humana, also saw stock declines. The company has faced mounting challenges, including increased health care usage, rate cuts, and a difficult period following the December shooting death of CEO Brian Thompson, which led to a sharp $100 drop in stock value. “UnitedHealth Stock Plummets Following US Medicare Billing Investigation Report,” CloudBrain, February 21, 2025.

Dr. Oz Tapped to Lead Medicare Despite Millions in Health Care Investments: President Trump’s pick to oversee the Centers for Medicare and Medicaid Services (CMS), Dr. Mehmet Oz, has reported owning up to $600,000 in stock from companies benefiting from private Medicare contracts. In 2022, Oz and his wife held at least $8.5 million in health care investments, including up to $550,000 in UnitedHealth Group stock and as much as $50,000 in CVS Health shares—both major Medicare Advantage insurers. As a Senate candidate, Oz promoted a “Medicare Advantage for All” plan, which would expand the privately run Medicare option despite research showing it costs taxpayers 22% more than traditional Medicare. “Dr. Oz is Trump’s Pick to Oversee Medicare. He Owns Healthcare Stocks That Could Benefit,” Quartz, November 20, 2024.

UnitedHealth Pushed Doctors to Inflate Diagnoses for Medicare Advantage Payments: Internal documents obtained by STAT News reveal that UnitedHealth pressured its physicians to add lucrative diagnoses to Medicare Advantage patients, boosting the company’s risk-adjusted payments by billions. A doctor leaderboard and $10,000 bonuses incentivized coding strategies that sometimes included clinically insignificant, marginally treatable, or even nonexistent conditions. The investigation exposes how UnitedHealth manipulated the payment system to maximize profits at Medicare’s expense. “Inside UnitedHealth’s Strategy to Pressure Physicians: $10,000 Bonuses and a Doctor Leaderboard,” STAT News, October 16, 2024.

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PNHP Chapter Reports

Arizona

The Arizona chapter held two legislative meetings with staff from Sen. Gallego and Rep. Ciscomani’s offices to discuss Medicaid cuts, Medicare Advantage, threats to the ACA, and global issues such as reductions to U.S. aid. Medicare Advantage was a central focus in both discussions. Chapter leaders have also been encouraging members to complete the moral injury survey.

To get involved in Arizona, contact Dr. Eve Shapiro at shapiroe@u.arizona.edu.

California

The Bay Area chapter has remained connected through ongoing monthly meetings, where members have engaged in discussions on health care issues, including the mental health crisis and the harms of privatization. One notable highlight was the publication of “My Brother’s Keeper: The Untold Stories Behind the Business of Mental Health—and How to Stop the Abandonment of the Mentally Ill” by psychiatrist Nick Rosenlicht in October, which sparked thoughtful conversation within the group.

To get involved in the Bay Area, contact Dr. Henry Abrons at habrons@gmail.com.

The Humboldt County chapter has been highly active throughout the year, engaging in local, state, and national advocacy. Highlights include hosting Assembly candidate Chris Rogers at a chapter meeting, launching a “stealth advocacy” program to counter local Medicare Advantage promotion, and raising significant funds at the North Country Fair booth. Members also participated in Pastels on the Plaza to promote single payer and engaged in media outreach through ads, op-eds, and radio interviews. Chapter leaders attended the PNHP Annual Meeting in Chicago, contributed to the Office of Health Care Affordability (OCHA) educational forum, and are working closely with the Movement to End the Privatization of Medicare. The chapter also endorsed the National Single Payer Day of Action on May 15 and remains deeply involved in advocacy against Medicare privatization.

To get involved in Humboldt County, contact Dr. Corinne Frugoni or Patty Harvey at healthcareforallhumboldt@gmail.com.

The Los Angeles chapter initially held hybrid monthly meetings at the Santa Monica Library, but due to low attendance, they have transitioned to more accessible Zoom meetings on the fourth Saturday morning of each month. These gatherings feature lectures and discussions on key health care topics, offering members a space to stay informed and engaged.

To get involved in Los Angeles, contact Dr. Nancy Niparko, nniparko@gmail.com, or Dr. Maleah Grover, mgm1payer@gmail.com.

A chapter member in Santa Barbara recently participated in a delegation to Cuba to observe their healthc are system and later presented a health policy seminar to share key takeaways. The chapter is also planning a legislative visit with their U.S. Representative on March 20 to discuss the harms of Medicare Advantage and to encourage support for Rep. Jayapal’s letter to CMS. Additionally, on April 1, the chapter will visit a local high school with two pre-med students to discuss the importance of single-payer health care.

To get involved in Santa Barbara, contact Dr. Nancy Greep at ncgreep@gmail.com.

Colorado

On February 27, the Colorado chapter hosted a powerful webinar titled “Denied,” featuring real-life experiences from U.S. and Canadian doctors and medical office staff. The panel highlighted the stark contrast between the two health care systems, particularly the ease of access and administration in Canada. The chapter continues to hold monthly joint meetings with PNHP members and Medical Professionals for Universal Healthcare, fostering collaboration and strategy-sharing. Recent recruitment efforts have resulted in 40 members signing up with expiration dates in 2026. Advocacy efforts have included outreach to four congressional offices, including Reps. Jeff Hurd and Jason Crow. The chapter also contacted Sens. Michael Bennet and John Hickenlooper, urging them to vote against the nominations of RFK Jr. and Dr. Mehmet Oz, and reached out to Rep. Diana DeGette to ask her to oppose Dr. Oz and support Rep. Jayapal’s letter to rein in Medicare Advantage overpayments and deceptive recruitment tactics.

To get involved in Colorado, contact Dr. Leslie Reitman at Les.reitman@gmail.com.

Georgia

Members of PNHP Georgia participate in a candlelight vigil for the uninsured on Feb. 16.

Georgia members met with the staff of Sens. Ossoff and Warnock, as well as Reps. Nikema Williams, Barry Loudermilk, and Rick Allen, to discuss the harms of Medicare Advantage and to encourage support for the Rep. Jayapal and Sen. Warren letters to CMS. Participants in these meetings included a large and engaged group of physicians, students, and advocates. On January 20, an op-ed by Dr. Belinda McIntosh and Dr. Toby Terwilliger was published in the Atlanta Journal-Constitution, raising awareness about the urgent need for a single-payer system. The chapter also co-hosted a candlelight vigil for the uninsured on February 16, featuring speakers and community members calling for universal health care. To support the Moral Injury campaign, the chapter hosted a one-hour training session focused on distributing the national survey to gather stories and data from health care workers.

To get involved in Georgia, contact Dr. Toby Terwilliger at toby.terwilliger@gmail.com.

Illinois

Drs. Sydney Doe (L) and Winnie Lin attend “Funny You Should Care” at Second City on Feb. 11.

Illinois chapter leaders Dr. Sydney Doe and Dr. Winnie Lin participated in Second City’s “Funny You Should Care” event to raise funds and share PNHP’s key talking points through comedy and performance. Dr. Doe also gave a talk on Medicare Advantage and the case for single payer at the Ethical Humanist Society in Skokie. Additionally, Dr. Monica Maalouf and Dr. Claudia Fegan took part in a virtual forum hosted by the Health & Medicine Policy Research Group on February 13. The chapter has also organized several legislative meetings to encourage support for Rep. Jayapal’s letter to CMS. On February 19, members met with Rep. Jan Schakowsky (represented by Drs. Peter Gann, Deborah Geismar, and Anna Fogel) and with Rep. Sean Casten’s staff (attended by Drs. Ameer Sharifzadeh and Peter Gann). On February 25, Colin Garon and Dr. Peter Orris met with Rep. Mike Quigley’s staff.

To get involved in Illinois, contact Dr. Sydney Doe at sydney.doe94@gmail.com.

Kentucky

Members in Kentucky have been active in both community outreach and media. They tabled at World Fest and the Pride Festival, distributing flyers and gathering petition signatures to promote Enhanced Medicare for All. Kentuckians for Single-Payer Health Care also helped reorganize the SNaHP chapter at the University of Louisville in February. Additionally, they regularly produce Single Payer Radio, covering topics such as reproductive rights, the dangers of Medicare Advantage, and broader issues in the U.S. health care system. PNHP information on Medicare Advantage is featured at events and on the radio.

To get involved in Kentucky, contact Kay Tillow at nursenpo@aol.com.

Maine

Maine members have been active on both the federal and state levels. Between January 29 and February 5, Maine AllCare board members and supporters met with staff from Sens. Angus King and Susan Collins, and Rep. Jared Golden, to express concerns about MA—specifically, its overpayments and the impact on patient care. They also urged each office to support Rep. Jayapal’s letter calling for reforms to the MA program. On the state level, Maine AllCare is supporting three state bills: a universal health care study bill, the creation of an All Maine Health Program, and a moratorium on private equity and REIT ownership of hospitals. In addition, Maine AllCare has launched an LTE team, resulting in over a dozen letters and op-eds published across major state newspapers in the past six months, advancing the message of publicly-funded universal health care.

To get involved in Maine, contact Dr. Henk Goorhuis at info@maineallcare.org.

North Carolina

The North Carolina chapter hosted their 30th Anniversary Annual Meeting on October 6, 2024, featuring Rose Roach as keynote speaker and a presentation by Dr. Diljeet Singh via Zoom. The chapter launched a new initiative, Action Hours, including one on February 4, 2025, to oppose the nomination of RFK Jr. as HHS Secretary, and another on March 10, 2025, focused on preventing cuts to Medicaid. Two chapter members were nationally recognized for their advocacy work: Rebecca Cerese received the Health Justice Advocate of the Year Award from Families USA and Dr. Eleanor Greene received the Founder’s Award for Excellence in Advocacy, presented by Dr. Vivek Murthy on behalf of Doctors for America at their National Leadership Conference in June 2024. The chapter also actively participated in PNHP webinars and has been engaged in educating colleagues and fellow advocates about the harms of Medicare Advantage and the need for a single-payer system.

To get involved in North Carolina, contact Dr. Eleanor Greene at eleanorgreene@northstate.net, or Dr. Conny Morrison at conny.morrison@healthcareforallnc.org.

Ohio

The Cincinnati chapter recruited five new members, including four physicians and one nurse, bringing their chapter roster from 15 to 20 members. Three members gave a combined 15 presentations on single-payer health care reform to audiences of physicians, nursing students, and community groups. In autumn, the chapter launched a petition drive urging Rep. Greg Landsman to support the Congressional Progressive Caucus’s efforts to reform Medicare Advantage. The campaign collected over 500 signatures, which were scheduled to be delivered to Rep. Landsman in person, and which most likely inspired him to sign Rep. Jayapal’s MA letter in March. The chapter has maintained an ongoing dialogue with Rep. Landsman and his health policy aide, providing research and articles on profiteering by MA insurers.

To get involved in Cincinnati, contact Dr. Philip K. Lichtenstein at lichtensteinphil1@gmail.com.

Virginia

Drs. Bob Devereaux (L) and Jay Brock join medical student Rachel Fox at Popular Democracy’s “March to Save Our Healthcare” in Washington, D.C. on March 12

The Virginia chapter has been active on multiple fronts. Members, especially Dr. Bruce Silverman and Sandra Klassen, worked with state legislators on a bill that would allow Medicare Advantage enrollees to switch to traditional Medicare without underwriting—an effort that was unsuccessful this session, but will be pursued again. The chapter also formed a coalition with Arlington Medicare for All and the Northern Virginia DSA to advocate for Medicare for All and oppose Medicare Advantage. Raymond Uymatiao, MS4, helped launch a new SNaHP chapter at Virginia Tech Carilion and spoke at the People’s Action protest at UnitedHealthcare in D.C. Additionally, fourth year medical student Rachel Fox spoke at a Popular Democracy-led rally that included both Rep. Jayapal and Sen. Sanders as speakers. She focused on fighting Medicaid cuts and MA overpayments.

To get involved in Virginia, contact Dr. Robert Devereaux at robdev56@icloud.com.

Washington

PNHP and SNaHP members attend the PNHP Annual Meeting in Chicago with Rep. Pramila Jayapal (front-center).

The Washington state chapter has been deeply engaged in coalition building and education. They serve on the Steering Committee of Health Care is a Human Right Washington and co-organized the first-ever Single-Payer Summit, bringing together representatives from 20 organizations committed to single payer. The summit group continues to meet regularly. The chapter also holds monthly meetings featuring speakers on timely health care issues and sent a delegation of 12 PNHPWA and SNaHP WA members to the PNHP Annual Meeting in Chicago.

To get involved in Washington, contact Dr. David McLanahan at mcltan@comcast.net.

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SNaHP Chapter Reports

SNaHP Rising (Western University)

SNaHP Rising (Western University) is among one of the newest chapters, and officially became recognized as a part of SNaHP on February 19. Their first meeting recruited eight medical students and included a discussion on the core arguments for single payer and the failures of MA. They also discussed the AAFP’s potential resolution opposing MA and encouraged students to submit their own testimonies to support.

To get involved with SNaHP Rising, contact Zollie Daily at zollie.daily@westernu.edu.

Florida SNaHP

Florida SNaHPers advocate for health care legislation during Lobby Day in Tallahassee on March 13.

Florida SNaHP members met with the offices of Reps. Maxwell Frost, Sheila Cherfilus-McCormick, Jared Moskowitz, and Frederica Wilson to encourage them to sign on to Rep. Jayapal’s letter calling for reform of Medicare Advantage. The chapter also hosted a powerful Town Hall with Reps. Jayapal and Cherfilus-McCormick to raise awareness about the dangers of Medicare privatization. The event drew 140 attendees on Zoom, and over 80 participants took action by emailing their representatives to oppose Medicare “Advantage.” In addition, the chapter held a successful Health Policy Week, adding over 60 new M1 members to their listserv and launching new student chapters at the UF undergraduate campus, UCF College of Medicine, and USF Morsani College of Medicine.

To get involved in Florida, contact Pat Haley at patrickhaley59@gmail.com.

FSU (Florida State University)

FSU (Florida State University) SNaHP members supported a February 2025 Town Hall featuring Rep. Pramila Jayapal and mobilized students during Medicare Open Enrollment with a national activist call. The chapter also met with Rep. Sheila Cherfilus-McCormick and participated in a June 2024 Town Hall with key health care leaders. Their efforts continue to raise awareness about the harms of Medicare Advantage and promote patient-centered reform.

To get involved with FSU SNaHP, contact Davalda Bellot at dmb12d@fsu.edu.

Health Care for All (Chicago College of Osteopathic Medicine)

The Health Care for All (Chicago College of Osteopathic Medicine) chapter hosted a screening and discussion of “The Healthcare Divide” to raise awareness about the disparities caused by our current health care system. They also organized a workshop on letter-writing campaigns, equipping participants with tools to effectively advocate for health care reform. Several members were actively involved in drafting and supporting resolutions related to Medicare Advantage, which were submitted to both the Illinois State Medical Society (ISMS) and the American Osteopathic Association (AOA).

To get involved with Health Care for All, contact Brittany Taylor at brittany.taylor1@midwestern.edu.

Northwestern SNaHP

In October 2024, Northwestern SNaHP students Samiya Manocha (M1) and Mo Kissinger (M4) collaborated with peers from other Illinois medical schools to write and submit a resolution to the Illinois State Medical Society (ISMS) urging greater transparency in Medicare Advantage plans. The resolution was recommended for adoption by committee and is set to be voted on in late April. From September to December 2024, students Emma Pauer and Laith Kayat (M2s) led a chapter book club on “Medicare for All: A Citizen’s Guide,” bringing members together for three in-depth discussions. The chapter also hosted a special event in December 2024, “A Conversation with Dr. Claudia Fegan,” where Dr. Fegan spoke to a large student audience about Medicare for All and international health care systems, sparking strong interest and dialogue.

To get involved at Northwestern, contact Becca Marcus at Rebecca.marcus@northwestern.edu.

University of Illinois College of Medicine – Peoria

The SNaHP chapter at the University of Illinois College of Medicine – Peoria held its first ever chapter meeting with an introductory lunch to kick off organizing efforts and build member engagement. Chapter leaders also attended the SNaHP conference, connecting with other medical students and advocates from across the country. In collaboration with UI Health residents and the Chicago PNHP chapter, the group began an investigation into billing practices at UI Health, aligning with broader efforts to uncover and address harmful health care system practices. They also shared the Moral Injury Survey with faculty to encourage participation and awareness.

To get involved in the Peoria chapter, contact Kelley Baumann at kbauma22@uic.edu.

Iowa SNaHP

Medical student Zach Grissom speaks during Sen. Bernie Sanders’ rally in Iowa City on Feb. 22.

The Iowa SNaHP chapter launched in fall 2024 and has quickly gained momentum. From having no formal structure in September, the group now has around 40 members on paper, with 17 actively involved in planning and executing events. Their programming is widely advertised to the entire College of Medicine MD and PA student body. The chapter’s first event, “Single Payer 101” with Dr. Arya Zandvakili, took place on October 24, 2024, followed by a student-led presentation on Medicare DISadvantage on December 4, 2024, which utilized Dr. Ed Weisbart’s “Naked Profiteering” slide deck to highlight the advantages of traditional Medicare over Medicare Advantage. Most recently, I-SNaHP members attended the Sen. Bernie Sanders rally in Iowa City on February 22, 2025, where Zach Grissom was one of the speakers who addressed the crowd before the Senator, speaking about MA and Medicaid work requirements.

To get involved with I-SNaHP, contact Zach Grissom at zach-grissom@uiowa.edu.

KYCOM (University of Pikeville – Kentucky College of Osteopathic Medicine)

In partnership with Midwestern University Chicago College of Osteopathic Medicine, the KYCOM (University of Pikeville – Kentucky College of Osteopathic Medicine) SNaHP chapter submitted a SOMA resolution on the harmful effects of MA. Serina Sajjad, Adam Sayler, and Sammy Jaber were key contributors to the resolution’s writing and editing. The chapter also implemented a Community Aid initiative within the school’s student-run free clinic, launching the Bear Cove, a mutual aid corner offering food, hygiene products, clothing, and reproductive health supplies. The initiative, led by Cassie Craig and in partnership with All Access EKY, includes ongoing donation drives, needs assessments, and plans to expand into harm reduction services like Narcan training and safe needle disposal. In February, the chapter launched a statewide medical debt relief campaign in collaboration with Undue Medical Debt, aiming to abolish $33 million in defaulted medical debt across Kentucky. They also hosted an on-campus presentation highlighting how MA’s practices limit care and increase corporate profit. This training supported their Medicare Advantage Bingo events at Myers Tower and Pikeville Nursing and Rehabilitation Center, where students educated residents using interactive games, word searches, and coloring sheets. The events were led by Sammy Jaber and Serina Sajjad and co-hosted with the KYCOM Geriatrics Club.

To get involved with KYCOM SNaHP, contact Evan Hawthorn at EvanHawthorn@upike.edu.

WMed SNaHP

WMed students launch their SNaHP chapter at a Nov. 21, 2024 kickoff meeting.

WMed SNaHP members launched their organizing efforts with a successful kickoff meeting on November 21, 2024. Chapter leadership presented on diabetes as a case for single payer health care to an audience of over 30 peers and gathered signatures for MI for Single Payer’s petition supporting the MICARE initiative for state-based Medicare for All. The chapter has also formed partnerships with Southwest Michigan DSA and Food Not Bombs, collaborating on two ongoing projects to serve the local community directly. In addition, chapter leaders attended the SNaHP Medicare Advantage meeting and have been distributing PNHP materials on Medicare Advantage to raise awareness among peers.

To get involved with the WMU Homer Stryker chapter, contact Genevieve Nicolow at genevieve.nicolow@wmed.edu.

Creighton SNaHP

The Creighton SNaHP chapter hosted two successful Undue Medical Debt fundraisers—Dance Off Debt on October 4 and a Bake Sale on January 27—raising over $8,500 to help eliminate medical debt. On the legislative front, members testified in support of a Nebraska state bill to strengthen protections against medical debt garnishment on January 24. Additionally, the chapter held meetings with the offices of Sen. Deb Fischer (2/11) and Rep. Don Bacon (2/12) to advocate for strengthening traditional Medicare and opposing Medicare Advantage rate hikes. The chapter also created and delivered an educational presentation, “How to Navigate the U.S. Health Care System,” for a local community organization. Accompanied by a handout and map translated into 13 languages, these materials were distributed at a local health fair and will soon be available on the chapter’s website to expand access even further.

To get involved with the Creighton chapter, contact Luci Lange at lkl94259@creighton.edu.

Jacobs SNaHP

In October, the Jacobs SNaHP chapter hosted a fun and educational SNaHP Trivia Night, with questions focused on single-payer health care. The event was held at a local bar and featured prizes for the top three teams, helping to engage students in a relaxed and informative setting. In addition to campus activities, the chapter has been collaborating with other SNaHP chapters across Western New York, meeting monthly to strategize on lobbying local politicians in support of health care justice and Medicare for All.

To get involved with the Jacobs SNaHP chapter, contact Dylan Wong at dkwong2@buffalo.edu or jacobssnahp@gmail.com.

SNaHP at NEOMED (Northeast Ohio Medical University)

In February, SNaHP at NEOMED (Northeast Ohio Medical University) board members Elsa Khan and Shannon Lam led a workshop as part of a required clinical skills and ethics course. Shannon Lam and Noyonikaa Gupta also published an op-ed in The Portager addressing concerns about proposed work requirements for Medicaid and Medicare. Members Helen Aziz and Shannon Lam also volunteered at the Teddy Bear Clinic to connect with children, helping foster an early interest in medicine and ease anxieties about visiting the doctor.

To get involved with the NEOMED SNaHP chapter, contact Shannon Lam at slam2@neomed.edu. 

DUCOM (Drexel University College of Medicine)

In August, the DUCOM (Drexel University College of Medicine) SNaHP chapter hosted a Single Payer 101 event to introduce incoming M1s to the concept of single-payer health care and the mission of SNaHP. Later in the year, former board member Justin Yeung organized a hybrid talk with Dr. Ed Weisbart, who presented on the dangers of Medicare Advantage followed by a Q&A session with medical students. In addition to educational events, the chapter also participated in voter registration canvassing during the summer and early fall, partnering with Penn Medicine to reach community members and promote civic engagement.

To get involved with DUCOM SNaHP, contact Kacie Wheeler at ducom.snahp@gmail.com.

SKMC (Sidney Kimmel Medical College)

This year, the SKMC (Sidney Kimmel Medical College) SNaHP chapter hosted several informative speaker events, including a session with Dr. Julie Qualtieri focused on Medicare Advantage and a visit from Dr. Joe Jarvis of Utah, who shared insights from the Utah Cares campaign and offered strategic lessons for Pennsylvania. Looking ahead, the chapter plans to increase event attendance and visibility on campus, beginning with an upcoming student-run workshop on the Affordable Care Act and threats to its subsidies under the Inflation Reduction Act. The chapter plans to continue outreach to local elected officials to promote single-payer policies and highlight the growing support among health care worker unions. In the policy space, the chapter is building connections with other student organizations at Jefferson. They are currently working with the Jefferson AMA chapter to organize a policy-writing workshop, with the goal of submitting single-payer focused resolutions to PAMED.

To get involved with the SKMC chapter, contact Emily Hashem at enh013@students.jefferson.edu.

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Responding to the UnitedHealthcare CEO Murder

Four months ago, the shocking news broke that the CEO of UnitedHealthcare had been shot and killed in Manhattan while on his way to the company’s annual investor conference. Public reaction to this event has been intense, sparking a national conversation about corporate control of health care and the deep frustration felt by Americans towards private insurance companies. This moment underscored a stark reality: Our health care system is in crisis, and people are suffering under the weight of corporate greed.

PNHP has been vocal in responding to this event, with our members highlighting the urgent need for Medicare for All as the only solution to the injustices perpetrated by private insurers. PNHP National Coordinator Dr. Claudia Fegan published a powerful op-ed in Common Dreams in early January, reflecting on her decades of difficult experiences, and how these are shared by millions of Americans who struggle to receive the care they need.

“I have seen patients suffer and die in order to pad the bottom lines of corporate health insurers,” she wrote, “and in recent years I have seen this problem getting much worse. These are the stories that Americans are sharing in this fraught moment. We have to ask ourselves: Are we listening? And what are we going to do about it?”

The public reaction to this shooting has made one thing clear: Americans are fed up with private insurers profiting off of denied care, surprise bills, and administrative hurdles that make it harder for patients to get the treatment they need. As this story dominated the news cycle, PNHP leaders and members took the opportunity to shift the conversation toward real solutions—not just outrage, but action. Our members have been speaking out in the media, engaging in public discussions, and emphasizing that the only way to truly end the suffering caused by corporate insurers is to replace them with a single-payer Medicare for All system.

This moment is a wake-up call, and we cannot afford to ignore it. PNHP will continue to fight for a health care system that puts patients before profits, and we urge our members and supporters to channel their frustration into advocacy.

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PNHP in the News

News items featuring PNHP members

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Op-eds by PNHP members

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Letters to the editor by PNHP members

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Sounding the Alarm on Moral Injury

Physicians for a National Health Program (PNHP) is partnering with the Robert Wood Johnson Foundation (RWJF) to study the impact of financialization on U.S. health care. We are engaging with current health care professionals to better understand moral injury and distress, how these issues impact racial inequities in health care, and how best to remedy this worsening problem.

See our initial survey findings

Stay engaged with our moral injury work

What is “moral injury?”

As health care has been transformed from an essential service to a profit-driven business, the morale of the entire workforce—including physicians, nurses, and allied health professionals—has suffered. This trend has led to shortages as professionals are retiring early, cutting back work hours, quitting clinical medicine, and tragically committing suicide in increasing numbers.

These responses have often been misdiagnosed as “burnout,” but the lack of efficacy of standard treatments for burnout has led insightful scholars such as Drs. Wendy Dean and Simon Talbot to identify “moral injury” as a more accurate culprit.

Moral injury in health care is described as the challenge of knowing what care patients need, but being unable to provide it due to constraints beyond physicians’ control. As a result, the industry’s focus on burnout is insufficient and, in fact, causes harm by leading to a reliance on ineffectual “wellness” programs and an obscuring of root causes.

Without adequate data on moral injury, the ability of policymakers and stakeholders to address our health care crisis will remain limited.

Moral injury survey findings

In an effort to better understand moral injury in health care, PNHP surveyed workers throughout the medical profession and conducted a series of one-on-one interviews with currently practicing physicians. We gathered data points on the impact of financialization from our survey, and identified narratives from our interviews to more compellingly illustrate these data points. These elements will form the basis of our upcoming report, which will provide actionable recommendations for stakeholders.

Our survey of health professionals—including 1,126 currently practicing physicians—yielded striking results. We found that 87% of physicians reported at least mild burnout while 69% of physicians have left or considered leaving a position due to moral injury or distress.

For more information on our initial findings, see our one-pager HERE and watch our “Understanding Moral Injury in Medicine” webinar HERE.

Sharing our moral injury work

Our physician members—and everybody who is concerned about the financialization of health care—have a crucial role to play in sharing our moral injury findings.

PNHP national board member Dr. Toby Terwilliger provides some tips on sharing the survey above, but his advice also applies to sharing our moral injury project as a whole. Please reach out to your colleagues today, share our survey data and your personal experiences with moral distress, and continue the conversation about how to substantively address these issues.

Moral injury buttons

PNHP’s brand new buttons are perfect for wearing and/or distributing to health professionals in your network. Interested in sparking conversations about moral injury? Email rebecca@pnhp.org and we’ll happily send some buttons to you!

Learn more about our research process

PNHP president Dr. Diljeet Singh helped lead a workshop on moral injury at our 2024 Annual Meeting in Chicago, where she gave a detailed overview of the topic. You can download Dr. Singh’s slideshow HERE.

We’ve also developed a one-page info sheet with information about the project.

Respecting our participants’ privacy

PNHP’s moral injury survey covered delicate topics and gave participants the opportunity to share experiences from their practice—as well as experiences with specific employers, insurers, and other parties.

Rest assured that survey responses were anonymized through the use of unique ID numbers and that nobody outside of PNHP’s survey team will ever have access to individual replies.

We also asked survey respondents to share their email address, so we could follow up regarding potential 1:1 interviews. Please note:

  • Individuals who were not already in PNHP’s database could opt in to receive updates about our moral injury project.
  • If respondents were added to our email list, they could unsubscribe at any time (link at the bottom of all PNHP emails).
  • PNHP will never sell or share emails collected through our moral injury survey.

Our project followed the rigorous practices of the Association for the Accreditation of Human Research Protection Programs (AAHRPP), and we obtained Institutional Review Board approval by the independent Pearl IRB, along with our consultant at Cambridge Health Alliance’s institutional IRB.

See the following documents for specifics on our survey, and the broader moral injury project: