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      Insurance Companies and the Prior Authorization Maze

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      More from our inbox:Elect the U.S. Attorney GeneralFriendship MemoriesA Leadership GapInsurance companies have weaponized a seemingly benign process to protect their profits, and it’s putting patients at risk.To the Editor:Re “‘What’s My Life Worth?’ The Big Business of Denying Medical Care,” by Alexander Stockton (Opinion video, March 14), about prior authorization:Mr. Stockton’s video captures a current snapshot of an important truth about medical insurance in our country and in doing so does a service to all citizens by making them aware of this threat to themselves and their families.The immediate truth is that medical insurance companies are inadequately regulated, monitored and punished for their greed. In their current iteration they are bastions of greed, power and money. They need to be reined in.But there are other truths as well. Some physicians, just like some pharmaceutical companies, are unable to contain their greed and allow avarice to cloud their judgment, compromise their ethics and in some cases cross the line to Medicare fraud or other illegal activity.Medical care in our country is very big business involving billions of dollars. Without proper controls, regulation and monitoring, malfeasance follows. The challenge in such a complex and multifaceted context is how to implement such controls and monitoring without making things worse.Ross A. AbramsJerusalemThe writer, a retired radiation oncologist, is professor emeritus at Rush University Medical Center in Chicago.To the Editor:The Times’s video exploits tragic outcomes and does not mention basic important facts about the limited yet key role of prior authorization in ensuring that patients receive evidence-based, affordable care.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe. More

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      A UnitedHealthcare and Mount Sinai Dispute May Force Thousands to Switch Doctors

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      As Mount Sinai Hospital and UnitedHealthcare haggle over pay rates, patients may have to pay out-of-network prices if they want to keep their doctors.Stalled contract negotiations between UnitedHealthcare, the health insurance giant, and Mount Sinai Health System, a leading New York City hospital system, are forcing tens of thousands of New Yorkers to switch doctors or risk paying out-of-network prices.The impasse has dragged on for months. Mount Sinai has sought to raise prices significantly, but the insurance company has refused to agree to pay the new proposed rates. As a result, Mount Sinai’s hospitals are now out of network for patients insured by UnitedHealthcare or Oxford, which are subsidiaries of the same company. But the issue is about to become even more urgent for many patients because many Mount Sinai affiliated doctors — in addition to the hospitals themselves — are about to be removed from UnitedHealthcare’s network, starting March 22. That means patients with United who have employer-sponsored or individual plans will be billed out-of-network rates when they see a Mount Sinai affiliated doctor at a doctor’s office.The negotiations have sent many patients scrambling to find new doctors. UnitedHealthcare says about 80,000 Mount Sinai patients are affected.What Happened?The dispute between the insurance giant and the hospital system is a rare instance in which health care contract negotiations have spilled into public view.Mount Sinai sought to negotiate better rates with UnitedHealthcare, demanding that the insurance giant pay the hospital more for doctor visits and hospital stays. United claims Mount Sinai was asking for rates to go up some 58 percent over the next four years.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe. More

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      ‘Fix the Damn Roads’: How Democrats in Purple and Red States Win

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      When Gov. Josh Shapiro of Pennsylvania got an emergency call about I-95 last June, his first thought turned to semantics. “When you say ‘collapse,’ do you really mean collapse?” he recalled wondering. Highways don’t typically do that, but then tractor-trailers don’t typically flip over and catch fire, which had happened on an elevated section of the road in Philadelphia.Shapiro’s second, third and fourth thoughts were that he and other government officials needed to do the fastest repair imaginable.“My job was: Every time someone said, ‘Give me a few days, and I’ll get back to you,’ to say, ‘OK, you’ve got 30 minutes,’” he told me recently. He knew how disruptive and costly the road’s closure would be and how frustrated Pennsylvanians would get.But he knew something else, too: that if you’re trying to impress a broad range of voters, including those who aren’t predisposed to like you, you’re best served not by joining the culture wars or indulging in political gamesmanship but by addressing tangible, measurable problems.In less than two weeks, the road reopened.Today, Shapiro enjoys approval ratings markedly higher than other Pennsylvania Democrats’ and President Biden’s. He belongs to an intriguing breed of enterprising Democratic governors who’ve had success where it’s by no means guaranteed, assembled a diverse coalition of supporters and are models of a winning approach for Democrats everywhere. Just look at the fact that when Shapiro was elected in 2022, it was with a much higher percentage of votes than Biden received from Pennsylvanians two years earlier. Shapiro won with support among rural voters that significantly exceeded other Democrats’ and with the backing of 14 percent of Donald Trump’s voters, according to a CNN exit poll that November.Biden’s fate this November, Democratic control of Congress and the party’s future beyond 2024 could turn, in part, on heeding Shapiro’s and like-minded Democratic leaders’ lessons about reclaiming the sorts of voters the party has lost.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe. More

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      6 Reasons That It’s Hard to Get Your Wegovy and Other Weight-Loss Prescriptions

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      An array of obstacles make it difficult for patients to obtain Wegovy or Zepbound. Finding Wegovy is “like winning the lottery,” one nurse practitioner said.Talk to people who have tried to get one of the wildly popular weight-loss drugs, like Wegovy, and they’ll probably have a story about the hoops they had to jump through to get their medication — if they could get it at all.Emily Weaver, a nurse practitioner in Cary, N.C., said she told her patients that finding Wegovy was “like winning the lottery.”Here are six reasons why.1. Demand is very high.Fueled in part by TikTok videos and celebrity testimonials, people are increasingly seeking prescriptions for appetite-suppressing medications. The drugs in this class have long been used to treat diabetes but more recently have been recognized for their extraordinary ability to help patients lose weight. The medications are injected weekly and have sticker prices as high as $16,000 a year.About 3.8 million people in the United States — four times the number two years ago — are now taking the most popular weight-loss drugs, according to the IQVIA Institute for Human Data Science, an industry data provider. Some of these prescriptions are for diabetes. The medicines are Novo Nordisk’s Ozempic and Wegovy (the same drug sold under different brand names), and Eli Lilly’s Mounjaro and Zepbound (also the same drug).We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber? Log in.Want all of The Times? Subscribe. More

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      Bidencare Is a Really Big Deal

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      In 2010, at the signing of the Affordable Care Act, a.k.a. Obamacare, Joe Biden, the vice president at the time, was caught on a hot mic telling President Barack Obama that the bill was a “big deal.” OK, there was actually another word in the middle. Anyway, Biden was right.And in one of his major unsung accomplishments — it’s amazing how many Americans believe that an unusually productive president hasn’t done much — President Biden has made Obamacare an even bigger deal, in a way that is improving life for millions of Americans.As you may have noticed — as many Americans finally seem to be noticing — Biden has been racking up some pretty good numbers lately. Economic growth is still chugging along, defying widespread predictions of a recession, while unemployment remains near a 50-year low. Inflation, especially using the measure preferred by the Federal Reserve, has fallen close to the Fed’s target. The stock market keeps hitting new highs.Oh, and murders have plummeted, with overall violent crime possibly hitting another 50-year low.Biden deserves some political reward for this good news, given that Donald Trump and many in his party predicted economic and social disaster if he were elected, and that Republicans, in general, are still talking as if America were suffering from high inflation and runaway crime. (Trump, of course, has been dismissing the good jobs numbers as fake. Wait until he hears about falling crime.)It’s less clear how much of the good news on these fronts can be attributed to Biden’s policies. Presidents definitely don’t control the stock market. They have less influence in general on the economy than many believe; I would give Biden some credit for the economy’s strength, which was in part driven by his spending policies, but the rapid disinflation of 2023 mainly reflects a nation working its way out of lingering disruptions from the Covid pandemic. The same is probably true for the plunge in violent crime.One area where presidents do make a big difference, however, is health care. Obamacare — which arguably should really be called Pelosicare, since Nancy Pelosi (who is not, whatever Trump may think, the same person as Nikki Haley) played a key role in getting it through Congress — led to big gains in health insurance coverage when it went into full effect in 2014.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber?  More

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      Fact-Checking Trump and Others’ Sparring Over Social Security and Medicare

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      The top presidential candidates are vowing to protect the entitlement programs for current seniors, though some have floated changes for younger generations. But they’ve muddied each other’s current positions.Top contenders for the 2024 presidential election in recent weeks have accused each other of jeopardizing Social Security and Medicare, key entitlement programs for seniors.The future of the programs has been fodder for endless political debate — and distortions — because of the long-term financial challenges they face.Social Security’s main trust fund is currently projected to be depleted in 2033, meaning the program would then be able to pay only about three-quarters of total scheduled benefits. Medicare, for its part, is at risk of not having enough money to fully pay hospitals by 2031.President Biden, former President Donald J. Trump, Nikki Haley, the former governor of South Carolina, and Gov. Ron DeSantis of Florida are among the candidates zeroing in on those vulnerabilities, often by referring to one another’s previous positions.Here’s a fact-check.WHAT WAS SAID“Trump in 2020: We will be cutting Social Security and Medicare”— Biden campaign in a December social media post that includes a clip of Mr. TrumpThis is misleading. The Biden campaign has repeatedly claimed that cutting the programs is one of Mr. Trump’s policies. But while Mr. Trump has in the past suggested he might entertain trims to entitlements, he has repeatedly vowed during his campaign to protect the programs.In this case, the Biden campaign shared a short clip of Mr. Trump during a Fox News town hall in March 2020 and ignored his clarification at the time.The clip shows a Fox News host, Martha MacCallum, telling Mr. Trump, “If you don’t cut something in entitlements, you’ll never really deal with the debt.”“Oh, we’ll be cutting, but we’re also going to have growth like you’ve never had before,” Mr. Trump responded.The Trump administration immediately walked back his comments and said he was referring to cutting deficits. “I will protect your Social Security and Medicare, just as I have for the past 3 years,” Mr. Trump wrote in a post a day later.During his time in office, Mr. Trump did propose some cuts to Medicare — though experts said the cost reductions would not have significantly affected benefits — and to Social Security’s programs for people with disabilities. They were not enacted by Congress.Like other candidates, including Mr. Biden, Mr. Trump has shifted his positions over time. In a 2000 book, Mr. Trump suggested, for people under 40, raising the age for receiving full Social Security retirement benefits to 70. Before that, he said he was open to the idea of privatizing the program, even if he did not like the concept. He no longer advances those positions.Former President Donald J. Trump suggested that the government could avert Social Security changes by expanding drilling, but experts say that would not be enough revenue.Doug Mills/The New York TimesLast January, the former president said in a video that “under no circumstances should Republicans vote to cut a single penny from Medicare or Social Security.” But he has not outlined a clear plan for keeping the programs solvent. The Trump campaign did not respond to a request for comment.Mr. Trump suggested last month that the government could avert any Social Security changes by expanding drilling in the United States, but experts say that is not feasible.“Dedicating current oil and gas leasing revenues to Social Security would cover less than 4 percent of its shortfall, and it would be impossible to fix Social Security even if all federal land were opened to drilling operations,” according to the Committee for a Responsible Federal Budget.WHAT WAS SAID“And unlike Ron DeSanctimonious, we will always protect Social Security and Medicare for our great seniors. He wanted to knock the hell out of Social Security and Medicare.”— Mr. Trump during a campaign rally in mid-DecemberThis is misleading. While in Congress, Mr. DeSantis supported budget frameworks that proposed raising the full Social Security retirement age to 70, but leaving the early retirement age the same. As a presidential candidate, he has said he would not cut Social Security for seniors but has at times expressed openness to changes for younger people without specifying what those are.Currently, workers are eligible for their full benefits at their full retirement age, which varies from 66 to 67 depending on year of birth. But recipients can qualify for reduced benefits as early as age 62.As a Florida congressman, Mr. DeSantis did vote for Republican budget proposals — which would not have changed the law on their own — that supported gradually raising the full retirement age for Social Security to 70. The proposals did not call for changing the early retirement age.Gov. Ron DeSantis has not made clear his plans for Medicare as he runs for president.Rachel Mummey for The New York TimesThe proposals also called for changes to Medicare, including by eventually increasing its retirement age to 67 or 70, from 65, and transitioning the program to “premium support,” in which the government would provide payments for seniors to shop for various health care plans.Mr. DeSantis has not made clear his plans for Medicare as he runs for president, but he has often rejected the idea of changing Social Security. “We’re not going to mess with Social Security as Republicans, I think that that’s pretty clear,” he said in March.That said, he has signaled openness to adjusting the program for younger people. In a July interview on Fox News, Mr. DeSantis said, “Talking about making changes for people in their 30s or 40s, so that the program’s viable, you know, that’s a much different thing, and that’s something that I think there’s going to need to be discussions on.”The DeSantis campaign did not respond to a request for comment.WHAT WAS SAID“Nikki Haley, she has claimed that the retirement age is way, way, way too low. That’s what she said. So you’ve got a lot of people that have worked hard their whole life. Life expectancy is declining in this country. It’s tragic, but it’s true. So to look at those demographic trends and say that you would jack it up so that people are not going to be able to have benefits. I mean, I don’t know why she’s saying that.”— Mr. DeSantis on CNN last monthThis needs context. Life expectancy in the United States dropped during the coronavirus pandemic, but it is inching back up. And Ms. Haley has only called for changes to Social Security for younger people — not unlike what Mr. DeSantis himself has entertained.“The way we deal with it is, we don’t touch anyone’s retirement or anyone who’s been promised in, but we go to people, like my kids in their 20s, when they’re coming into the system, and we say, ‘The rules have changed,’” Ms. Haley said in an August interview with Bloomberg. “We change retirement age to reflect life expectancy.”Ms. Haley did not specify what the new retirement age should be. “What we do know is 65 is way too low, and we need to increase that,” she said when pressed. “We need to do it according to life expectancy.”Nikki Haley has suggested changing the Social Security retirement age for younger generations.Jordan Gale for The New York TimesMs. Haley also called for determining benefit adjustments based on inflation, rather than the current cost-of-living calculation, and limiting benefits for the wealthy.On Medicare, Ms. Haley has proposed expanding Medicare Advantage, under which private companies provide plans and are paid by the government to cover the beneficiary.Yet for 2023, the government was projected to spend $27 billion more for Medicare Advantage plans than if those enrollees were in traditional Medicare. Experts note that expanding Medicare Advantage while achieving overall savings would require structural changes that would be politically challenging to implement.“It would require a change in payment policy that would likely run into fierce opposition,” said Tricia Neuman, senior vice president at the health nonprofit KFF and executive director for its program on Medicare policy.Curious about the accuracy of a claim? Email factcheck@nytimes.com. More

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      Americans Are Signing Up for Obamacare in Record Numbers

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      The NewsMore than 15 million people have signed up for health insurance plans offered on the Affordable Care Act’s federal marketplace, a 33 percent increase compared to the same time last year, according to preliminary data released by the Biden administration on Wednesday.Federal health officials project that more than 19 million people will enroll in 2024 coverage by the end of the current enrollment period next month. That total would include those who gain coverage through state marketplaces, continuing the record-setting pace.“It means more Americans have the peace of mind of knowing that going to the doctor won’t empty their bank account,” Xavier Becerra, the health and human services secretary, said in a statement.An Affordable Care Act sign-up kiosk in a mall in Miami this month.Rebecca Blackwell/Associated PressWhy It Matters: The Affordable Care Act is expanding its reach.Despite a recent warning from former President Donald J. Trump, the front-runner in the race for the 2024 Republican presidential nomination, that he was “seriously looking at alternatives” to the Affordable Care Act, the latest surge in marketplace enrollment is a testament to the law’s enduring power.Legislation passed earlier in the Covid-19 pandemic increased federal subsidies for people buying plans, lowering the costs for many Americans. The Biden administration also lengthened the sign-up period and increased advertising for the program and funding for so-called navigators who help people enroll.“More and more people are realizing they can come onto the marketplace,” said Cynthia Cox, the director of the Program on the Affordable Care Act at KFF, a nonprofit health policy research group.She added: “Just because the A.C.A. has been around for a while doesn’t mean people who need to sign up for it know how to do that.”One Eye-Popping Statistic: 750,000 sign-ups in a single day.On Dec. 15 — the deadline to sign up for coverage that begins on Jan. 1 — nearly 750,000 people opted for a marketplace plan on HealthCare.gov. It was the largest single-day total yet.Dr. Benjamin Sommers, a health economist at Harvard who served in the Biden administration, said that improved outreach helped explain the record sign-ups. “I’m pleasantly surprised,” he said.We are having trouble retrieving the article content.Please enable JavaScript in your browser settings.Thank you for your patience while we verify access. If you are in Reader mode please exit and log into your Times account, or subscribe for all of The Times.Thank you for your patience while we verify access.Already a subscriber?  More

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      Dean Phillips, an Upstart Challenger to Biden, Embraces ‘Medicare for All’

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      A longtime moderate, the Democratic congressman now says he had been “convinced through propaganda” that calls for universal health care were “a nonsensical leftist notion.”As he mounts a long-shot primary challenge to President Biden, Representative Dean Phillips says he has had an epiphany about American health care policy.Gone is his yearslong skepticism about adopting a national single-payer health care system. Now Mr. Phillips, a moderate Democrat from Minnesota, is embracing the “Medicare for all” proposal championed in two presidential campaigns by Senator Bernie Sanders — whose former top aide is now advising Mr. Phillips’s campaign.Mr. Phillips said in an interview on Tuesday that he would join as a co-sponsor to a House proposal that would expand Medicare by creating a national health insurance program available to all Americans, a shift that comes seven weeks into a presidential campaign that has yet to show significant progress in public polling.“I was a good example of someone who had been convinced through propaganda that it was a nonsensical leftist notion,” Mr. Phillips said. “It’s not. It really isn’t. And that’s I think that’s part of my migration, if you will, a migration of understanding and due diligence and intellectual curiosity and most importantly, listening to people.”Embracing the House bill is a low-stakes maneuver. With Republicans in control of the chamber, there is little chance it will come to a vote. Even when Representative Nancy Pelosi of California was speaker, Democrats never held a vote on proposals for Medicare for all that were championed by their progressive caucus — largely because President Biden didn’t support such a move, and centrist Democrats believed it was a bridge too far.Mr. Phillips — who spoke in the interview by videoconference, from an onscreen profile identifying him as “Generic Democrat” in a sly nod to the party’s best performer in polls — argued that his recent evolution on health care was not an effort to outflank Mr. Biden from the left.Instead, he said, he has become convinced that expanding Medicare, the government-run insurance program for older people, to cover all Americans would end up saving the federal government money and should attract support not just from progressives but also from conservatives — including backers of former President Donald J. Trump.“This is not a Hail Mary, by any stretch,” Mr. Phillips said. “It’s not an olive branch to progressives. You know what it really is? It’s an invitation to Trumpers.”Mr. Biden’s campaign spokesman, Kevin Munoz, declined to comment about Mr. Phillips.Mr. Phillips, a businessman who grew wealthy helping to run his family’s liquor distilling empire and later helped build a gelato behemoth, is a former board chairman of Allina Health, one of Minnesota’s largest health care systems. He said his beliefs began to change about 10 years ago, when his daughter Pia, then 13, received a diagnosis of Hodgkin’s lymphoma, and he saw “the gaps between the haves and the have-nots.”In July 2020, as a first-term congressman, he embraced a “state public option” that would allow Americans to buy into Medicaid. More recently, he said, he has been consulting with Representative Pramila Jayapal of Washington, the chair of the Congressional Progressive Caucus, who is a lead sponsor of the House Medicare for all bill, backed by more than half of House Democrats.Mr. Biden has moved the Democratic conversation about health care away from the idea of a single-payer plan, focusing instead on narrower issues like lowering drug costs and improving maternal health.“This is not a serious proposal in today’s environment,” Leslie Dach, the chair of the health advocacy group Protect Our Care and a former Obama administration official, said of Mr. Phillips’s switch. “We’re living in an era where it takes all of our energy to protect what we have from Republicans in Congress.” Mr. Phillips has not gained much traction. A poll last month from CNN and the University of New Hampshire found that he had support from about 10 percent of likely Democratic primary voters in New Hampshire, the only state where he has a campaign apparatus. Mr. Biden’s name will not be on the ballot there, but the same CNN poll found that 65 percent of voters said they would write in his name.Mr. Phillips said he hoped to do well in New Hampshire before moving on to Michigan, where Mr. Biden’s approval ratings in recent polls have taken a hit from Black and Arab American voters who disapprove of his support for Israel in its war against Hamas.But Mr. Phillips offered little in the way of daylight between himself and Mr. Biden on that conflict, which has left Democratic voters fiercely divided. The congressman said that he would not call for an immediate cease-fire and that he did not consider Israel “an apartheid state,” as many on the left argue.Yet Mr. Phillips contended that Democrats were so disenchanted with Mr. Biden that when presented with another option, they would take it. “The good news is that 66 percent of the country does not yet hate me,” Mr. Phillips said, in a dig at the president’s dismal approval ratings. “America has already made up its mind about President Biden and Vice President Harris.” More