Loren Adler
@lorenadler.bsky.social
Fellow and Associate Director, Brookings Institution Center on Health Policy | mostly health econ, occasionally budgets or Knicks
An important point that the Big Beautiful Bill, as currently constructed, would barely dent federal spending when you factor in the added interest costs on the increased federal debt.
Lots of damage for such a minimal net spending reduction.
www.nytimes.com/2025/06/09/o...
Lots of damage for such a minimal net spending reduction.
www.nytimes.com/2025/06/09/o...
June 9, 2025 at 7:17 PM
An important point that the Big Beautiful Bill, as currently constructed, would barely dent federal spending when you factor in the added interest costs on the increased federal debt.
Lots of damage for such a minimal net spending reduction.
www.nytimes.com/2025/06/09/o...
Lots of damage for such a minimal net spending reduction.
www.nytimes.com/2025/06/09/o...
CBO predicts the House-passed work requirements would cause 4.8 million more people to go uninsured, most of whom the evidence suggests are likely to be working or should be exempt
Excellent op-ed today describing some of the on-the-ground challenges: www.nytimes.com/2025/06/08/o...
Excellent op-ed today describing some of the on-the-ground challenges: www.nytimes.com/2025/06/08/o...
June 9, 2025 at 6:44 PM
CBO predicts the House-passed work requirements would cause 4.8 million more people to go uninsured, most of whom the evidence suggests are likely to be working or should be exempt
Excellent op-ed today describing some of the on-the-ground challenges: www.nytimes.com/2025/06/08/o...
Excellent op-ed today describing some of the on-the-ground challenges: www.nytimes.com/2025/06/08/o...
More bureaucracy, more paperwork, and a less efficient government.
No more coverage lifeline for people between jobs.
That's what prior attempts with Medicaid work requirements have delivered, all without even increasing employment.
No more coverage lifeline for people between jobs.
That's what prior attempts with Medicaid work requirements have delivered, all without even increasing employment.
June 9, 2025 at 6:44 PM
More bureaucracy, more paperwork, and a less efficient government.
No more coverage lifeline for people between jobs.
That's what prior attempts with Medicaid work requirements have delivered, all without even increasing employment.
No more coverage lifeline for people between jobs.
That's what prior attempts with Medicaid work requirements have delivered, all without even increasing employment.
A helpful rundown of the House-passed reconciliation bill's effects on Medicaid & the ACA, including how its scale compares to the 2017 repeal & replace efforts
www.brookings.edu/articles/new...
www.brookings.edu/articles/new...
June 5, 2025 at 8:23 PM
A helpful rundown of the House-passed reconciliation bill's effects on Medicaid & the ACA, including how its scale compares to the 2017 repeal & replace efforts
www.brookings.edu/articles/new...
www.brookings.edu/articles/new...
From CBO:
• 11.8 million lose coverage due to One Big Beautiful Bill provisions
• 16M fewer w/ coverage in 2034 when incorporating the 4.2M expected coverage loss from expiration of enhanced ACA subsidies
That's a 57% ↑ in # of uninsured compared to June 2024 current policy projection
• 11.8 million lose coverage due to One Big Beautiful Bill provisions
• 16M fewer w/ coverage in 2034 when incorporating the 4.2M expected coverage loss from expiration of enhanced ACA subsidies
That's a 57% ↑ in # of uninsured compared to June 2024 current policy projection
June 4, 2025 at 7:08 PM
From CBO:
• 11.8 million lose coverage due to One Big Beautiful Bill provisions
• 16M fewer w/ coverage in 2034 when incorporating the 4.2M expected coverage loss from expiration of enhanced ACA subsidies
That's a 57% ↑ in # of uninsured compared to June 2024 current policy projection
• 11.8 million lose coverage due to One Big Beautiful Bill provisions
• 16M fewer w/ coverage in 2034 when incorporating the 4.2M expected coverage loss from expiration of enhanced ACA subsidies
That's a 57% ↑ in # of uninsured compared to June 2024 current policy projection
Plenty of ways to save big $$ w/o taking health insurance from >10 million & ↑ costs for millions more.
Here's one alternative path: www.healthaffairs.org/content/fore...
From a fiscal perspective, even better would be to ditch the bill's net tax cuts that will add trillions to our debt.
Here's one alternative path: www.healthaffairs.org/content/fore...
From a fiscal perspective, even better would be to ditch the bill's net tax cuts that will add trillions to our debt.
May 23, 2025 at 1:51 PM
Plenty of ways to save big $$ w/o taking health insurance from >10 million & ↑ costs for millions more.
Here's one alternative path: www.healthaffairs.org/content/fore...
From a fiscal perspective, even better would be to ditch the bill's net tax cuts that will add trillions to our debt.
Here's one alternative path: www.healthaffairs.org/content/fore...
From a fiscal perspective, even better would be to ditch the bill's net tax cuts that will add trillions to our debt.
In the search for spending savings, House Republicans could've gone after overpayments to insurers & hospitals in Medicare.
Instead, they singled out people w/ the lowest incomes for the lion's share of cuts.
Then re-directed that $$ mainly for more high-income tax cuts.
Instead, they singled out people w/ the lowest incomes for the lion's share of cuts.
Then re-directed that $$ mainly for more high-income tax cuts.
May 23, 2025 at 1:51 PM
In the search for spending savings, House Republicans could've gone after overpayments to insurers & hospitals in Medicare.
Instead, they singled out people w/ the lowest incomes for the lion's share of cuts.
Then re-directed that $$ mainly for more high-income tax cuts.
Instead, they singled out people w/ the lowest incomes for the lion's share of cuts.
Then re-directed that $$ mainly for more high-income tax cuts.
Quick summary of the "big, beautiful bill":
>10 million more uninsured
>1 million low-income seniors see higher Medicare premiums & cost-sharing
Large ACA premium ↑
~ 30% cuts to SNAP
~ $3 trillion in new debt
Makes low-income households worse off & high-income households better off.
>10 million more uninsured
>1 million low-income seniors see higher Medicare premiums & cost-sharing
Large ACA premium ↑
~ 30% cuts to SNAP
~ $3 trillion in new debt
Makes low-income households worse off & high-income households better off.
May 22, 2025 at 2:19 PM
Quick summary of the "big, beautiful bill":
>10 million more uninsured
>1 million low-income seniors see higher Medicare premiums & cost-sharing
Large ACA premium ↑
~ 30% cuts to SNAP
~ $3 trillion in new debt
Makes low-income households worse off & high-income households better off.
>10 million more uninsured
>1 million low-income seniors see higher Medicare premiums & cost-sharing
Large ACA premium ↑
~ 30% cuts to SNAP
~ $3 trillion in new debt
Makes low-income households worse off & high-income households better off.
Unclear if mandating full rebate passthrough to employers ends up ↑ or ↓ payer costs (& in turn premiums). Similar open question with delinking PBM renumeration from rebates.
Effects likely small either way, particularly at current levels of payer/PBM integration.
www.brookings.edu/articles/a-b...
Effects likely small either way, particularly at current levels of payer/PBM integration.
www.brookings.edu/articles/a-b...
December 17, 2024 at 10:17 PM
Unclear if mandating full rebate passthrough to employers ends up ↑ or ↓ payer costs (& in turn premiums). Similar open question with delinking PBM renumeration from rebates.
Effects likely small either way, particularly at current levels of payer/PBM integration.
www.brookings.edu/articles/a-b...
Effects likely small either way, particularly at current levels of payer/PBM integration.
www.brookings.edu/articles/a-b...
Re: extenders package: punchbowl.news/file_3769/
No Medicare site-neutral reforms, likely the most impactful cost containment provision debated.
Billing transparency for hospital depts should help a little at the margin.
Employer-facing PBM transparency provision could help reduce costs slightly.
No Medicare site-neutral reforms, likely the most impactful cost containment provision debated.
Billing transparency for hospital depts should help a little at the margin.
Employer-facing PBM transparency provision could help reduce costs slightly.
December 17, 2024 at 10:17 PM
Re: extenders package: punchbowl.news/file_3769/
No Medicare site-neutral reforms, likely the most impactful cost containment provision debated.
Billing transparency for hospital depts should help a little at the margin.
Employer-facing PBM transparency provision could help reduce costs slightly.
No Medicare site-neutral reforms, likely the most impactful cost containment provision debated.
Billing transparency for hospital depts should help a little at the margin.
Employer-facing PBM transparency provision could help reduce costs slightly.
CBO also details how much $$ can be saved from equalizing hospital outpatient payments in Medicare to what independent physician offices get paid, even before accounting for the reduced incentive for hospitals to buy up physician practices.
December 12, 2024 at 8:13 PM
CBO also details how much $$ can be saved from equalizing hospital outpatient payments in Medicare to what independent physician offices get paid, even before accounting for the reduced incentive for hospitals to buy up physician practices.
CBO also details a perennial favorite to add a patient OOP limit to Traditional Medicare, combine Parts A & B, & restrict Medigap.
Could easily use some savings from reducing MA plan overpayments to avoid the cost-sharing increases before the new OOP cap in this option.
Could easily use some savings from reducing MA plan overpayments to avoid the cost-sharing increases before the new OOP cap in this option.
December 12, 2024 at 7:47 PM
CBO also details a perennial favorite to add a patient OOP limit to Traditional Medicare, combine Parts A & B, & restrict Medigap.
Could easily use some savings from reducing MA plan overpayments to avoid the cost-sharing increases before the new OOP cap in this option.
Could easily use some savings from reducing MA plan overpayments to avoid the cost-sharing increases before the new OOP cap in this option.
CBO's out with their new deficit reductions options.
Just look at all that $$ on the table if we paid Medicare Advantage plans closer to what the law intended.
www.cbo.gov/system/files...
Just look at all that $$ on the table if we paid Medicare Advantage plans closer to what the law intended.
www.cbo.gov/system/files...
December 12, 2024 at 7:47 PM
CBO's out with their new deficit reductions options.
Just look at all that $$ on the table if we paid Medicare Advantage plans closer to what the law intended.
www.cbo.gov/system/files...
Just look at all that $$ on the table if we paid Medicare Advantage plans closer to what the law intended.
www.cbo.gov/system/files...
If the appeal's denied, they could submit & get covered a bill for the target time.
Given there's an in-network contract, there's likely no option to bill the patient for the denied claim (though this could depend on specific contract language).
Given there's an in-network contract, there's likely no option to bill the patient for the denied claim (though this could depend on specific contract language).
December 9, 2024 at 2:47 PM
If the appeal's denied, they could submit & get covered a bill for the target time.
Given there's an in-network contract, there's likely no option to bill the patient for the denied claim (though this could depend on specific contract language).
Given there's an in-network contract, there's likely no option to bill the patient for the denied claim (though this could depend on specific contract language).
Given all the misstatements flying around about the Anthem anesthesia coverage proposed change then retraction, my attempt at a bit of explanation.
Quick(ish) 🧵
Quick(ish) 🧵
December 9, 2024 at 2:47 PM
Given all the misstatements flying around about the Anthem anesthesia coverage proposed change then retraction, my attempt at a bit of explanation.
Quick(ish) 🧵
Quick(ish) 🧵
Two great health economist openings in the Health Analysis Division of the Congressional Budget Office (CBO).
phg.tbe.taleo.net/phg03/ats/ca...
phg.tbe.taleo.net/phg03/ats/ca...
December 8, 2024 at 3:43 PM
Two great health economist openings in the Health Analysis Division of the Congressional Budget Office (CBO).
phg.tbe.taleo.net/phg03/ats/ca...
phg.tbe.taleo.net/phg03/ats/ca...
4)
So far the prices emerging from IDR have been very high relative to pre-law prices, but how much can we extrapolate?
For EM, we find that nearly half the claims disputed in 2023 were between United & TeamHealth.
So far the prices emerging from IDR have been very high relative to pre-law prices, but how much can we extrapolate?
For EM, we find that nearly half the claims disputed in 2023 were between United & TeamHealth.
December 6, 2024 at 8:22 PM
4)
So far the prices emerging from IDR have been very high relative to pre-law prices, but how much can we extrapolate?
For EM, we find that nearly half the claims disputed in 2023 were between United & TeamHealth.
So far the prices emerging from IDR have been very high relative to pre-law prices, but how much can we extrapolate?
For EM, we find that nearly half the claims disputed in 2023 were between United & TeamHealth.
3)
We find some surprisingly low QPAS, including 6.3% below the Medicare price. The averages also look lower than expected, though unclear how much is a selection effect vs. shenanigans or other reasons.
For longer discussion: www.brookings.edu/articles/out...
We find some surprisingly low QPAS, including 6.3% below the Medicare price. The averages also look lower than expected, though unclear how much is a selection effect vs. shenanigans or other reasons.
For longer discussion: www.brookings.edu/articles/out...
December 6, 2024 at 8:22 PM
3)
We find some surprisingly low QPAS, including 6.3% below the Medicare price. The averages also look lower than expected, though unclear how much is a selection effect vs. shenanigans or other reasons.
For longer discussion: www.brookings.edu/articles/out...
We find some surprisingly low QPAS, including 6.3% below the Medicare price. The averages also look lower than expected, though unclear how much is a selection effect vs. shenanigans or other reasons.
For longer discussion: www.brookings.edu/articles/out...
2)
The No Surprises Act has been especially generous to large, PE-backed groups, who brought 92% of the EM disputes
PE-backed groups are winning 90% of time vs just 39% for other groups, generating an average IDR payment 63% higher relative to the QPA than non-PE groups.
The No Surprises Act has been especially generous to large, PE-backed groups, who brought 92% of the EM disputes
PE-backed groups are winning 90% of time vs just 39% for other groups, generating an average IDR payment 63% higher relative to the QPA than non-PE groups.
December 6, 2024 at 8:22 PM
2)
The No Surprises Act has been especially generous to large, PE-backed groups, who brought 92% of the EM disputes
PE-backed groups are winning 90% of time vs just 39% for other groups, generating an average IDR payment 63% higher relative to the QPA than non-PE groups.
The No Surprises Act has been especially generous to large, PE-backed groups, who brought 92% of the EM disputes
PE-backed groups are winning 90% of time vs just 39% for other groups, generating an average IDR payment 63% higher relative to the QPA than non-PE groups.
1 cont.)
Importantly, the prices emerging from IDR are also far higher than independent estimates of pre-law median in-network prices:
www.brookings.edu/articles/out...
Importantly, the prices emerging from IDR are also far higher than independent estimates of pre-law median in-network prices:
www.brookings.edu/articles/out...
December 6, 2024 at 8:22 PM
1 cont.)
Importantly, the prices emerging from IDR are also far higher than independent estimates of pre-law median in-network prices:
www.brookings.edu/articles/out...
Importantly, the prices emerging from IDR are also far higher than independent estimates of pre-law median in-network prices:
www.brookings.edu/articles/out...
We focused on the most commonly disputed service, a moderate to severe emergency medicine visit.
1) Prices emerging from the independent dispute resolution (IDR) process are far higher (2.65x) than insurer-calculated 2019 median in-network rates (qualifying payment amount, QPA)
1) Prices emerging from the independent dispute resolution (IDR) process are far higher (2.65x) than insurer-calculated 2019 median in-network rates (qualifying payment amount, QPA)
December 6, 2024 at 8:22 PM
We focused on the most commonly disputed service, a moderate to severe emergency medicine visit.
1) Prices emerging from the independent dispute resolution (IDR) process are far higher (2.65x) than insurer-calculated 2019 median in-network rates (qualifying payment amount, QPA)
1) Prices emerging from the independent dispute resolution (IDR) process are far higher (2.65x) than insurer-calculated 2019 median in-network rates (qualifying payment amount, QPA)
New research on No Surprises Act arbitration in #HAScholar w/ Erin Duffy, Chris Garmon, Adam Biener, & Erin Trish
Quick 🧵 w/ a few takeaways on who's using the process, how much better PE-backed groups are faring than competitors, & some surprisingly low QPAs.
academic.oup.com/healthaffair...
Quick 🧵 w/ a few takeaways on who's using the process, how much better PE-backed groups are faring than competitors, & some surprisingly low QPAs.
academic.oup.com/healthaffair...
December 6, 2024 at 8:22 PM
New research on No Surprises Act arbitration in #HAScholar w/ Erin Duffy, Chris Garmon, Adam Biener, & Erin Trish
Quick 🧵 w/ a few takeaways on who's using the process, how much better PE-backed groups are faring than competitors, & some surprisingly low QPAs.
academic.oup.com/healthaffair...
Quick 🧵 w/ a few takeaways on who's using the process, how much better PE-backed groups are faring than competitors, & some surprisingly low QPAs.
academic.oup.com/healthaffair...
At its core, this is a contractual dispute about how to pay for anesthesia that's best left for actual contract negotiations.
There you can argue about overbilling, or alternatively beef up audits/checks: pmc.ncbi.nlm.nih.gov/articles/PMC...
There you can argue about overbilling, or alternatively beef up audits/checks: pmc.ncbi.nlm.nih.gov/articles/PMC...
December 5, 2024 at 11:07 PM
At its core, this is a contractual dispute about how to pay for anesthesia that's best left for actual contract negotiations.
There you can argue about overbilling, or alternatively beef up audits/checks: pmc.ncbi.nlm.nih.gov/articles/PMC...
There you can argue about overbilling, or alternatively beef up audits/checks: pmc.ncbi.nlm.nih.gov/articles/PMC...
Well that didn't take long: providernews.anthem.com/connecticut/...
After a couple days of tweets making the Anthem anesthesia policy sound either much more egregious or much more sanguine than it really was.
After a couple days of tweets making the Anthem anesthesia policy sound either much more egregious or much more sanguine than it really was.
December 5, 2024 at 10:50 PM
Well that didn't take long: providernews.anthem.com/connecticut/...
After a couple days of tweets making the Anthem anesthesia policy sound either much more egregious or much more sanguine than it really was.
After a couple days of tweets making the Anthem anesthesia policy sound either much more egregious or much more sanguine than it really was.
CBO explains that the cost savings from banning facility fees for telehealth in the commercial market would be small & erode over time because the policy changes nothing about the relative market power of hospitals vs. payers.
www.cbo.gov/system/files...
www.cbo.gov/system/files...
November 15, 2024 at 3:58 PM
CBO explains that the cost savings from banning facility fees for telehealth in the commercial market would be small & erode over time because the policy changes nothing about the relative market power of hospitals vs. payers.
www.cbo.gov/system/files...
www.cbo.gov/system/files...