Ep 14: Medicare's Privatization Path & The $83 Billion Question with Tricia Neuman (KFF)

RECORDED BEFORE THE HOUSE RECONCILIATION BILL PASSED - Tricia Neuman of KFF's predictions proved accurate THE REALITY: 55% of Medicare beneficiaries are now in private Medicare Advantage plans, yet Medicare pays $83 BILLION more annually for these enrollees than similar patients in traditional Medicare. That's more than what Medicare spends on ALL physician payments combined. In this prescient conversation with KFF's Tricia Neuman, we explore the hard truths about Medicare's trajectory.

Introduction and Context for the Episode

Hi, everyone. I'm Dr. Anthony Paravati, and welcome to episode 14 of the Value Health Voices podcast. Before we dive into today's conversation, I want to give you some context that makes this episode even more relevant than when we recorded it earlier this month. We sat down with Tricia Neuman from KFF a couple of weeks before the House passed their massive budget reconciliation bill by a single vote.

In our conversation, Tricia warned about exactly what was coming: the $880 billion in Medicaid cuts, Medicare payment challenges, and the broader trajectory of the Medicare program towards privatization. Well, as you know by now, on May 22, it happened. The House pushed through their legislation that includes those very Medicaid cuts that Tricia discusses, along with a Medicare physician payment fix that falls far short of what virtually all analysts say is needed.

What makes this conversation so valuable is that you're hearing from one of the country's most trusted Medicare policy experts. Before the political pressure and the spin kicked in, Tricia gives you the unvarnished analysis of what makes these changes significant for patients, providers, and the future of American healthcare. As you listen, remember, this isn't just policy discussion or theory anymore. This is the roadmap that's moving now from the House to the Senate, where the fate of the bill remains uncertain. So let's get to that conversation with Tricia Neuman recorded back on May 7, when these were just proposals on the table.

Introducing Tricia Neuman and KFF

Good evening. We're back with another episode of Value Health Voices. As you know, our audience for this show is physicians, healthcare executives, policy wonks—vastly different roles in the healthcare ecosystem. But one thing it seems that everybody has in common is a deepening worry about Medicare's trajectory, its future. Today's conversation will hopefully ground that concern in some fact, history, and maybe even some hope.

And we are very, very fortunate to have Tricia Neuman as our guest today. She is a senior vice president of KFF and executive director of its program on Medicare policy. She has written numerous papers pertaining to Medicare, has been invited several times to present expert testimony before congressional committees, and has appeared and been quoted as an independent expert by major national media outlets. So we're very excited to have you.

Thank you for having me. I'm excited to be here.

We'll get right into several topics on the show right after our intro.

Tricia, thank you again for being with us. In my opening line, I mentioned the Medicare program. We're going to talk about a lot of things tonight, not just Medicare, but it's always the topic on everyone's mind. I guess I would describe it, and you tell me if I'm wrong, that the program today is at an inflection point politically, structurally, and fiscally.

One of the reasons we wanted to have you on the show is that few people, in my view, have watched it so closely evolve and really analyzed the impact of the program's changes more profoundly than you. And it's great to have you not only because of your expertise personally, but your role with KFF, which has a unique role in the US healthcare policy landscape because you are a nonpartisan data and information source relied upon by policymakers, journalists, provider groups, et cetera.

So let's get right into our first question. You've been one of the country's most trusted voices on Medicare. When you first started this work, what was your biggest concern and how has that changed?

My guiding light has always been the same, which is: how is this program working for people? The issues have changed over the years, but my focus has always been on the people who are covered by the program. What's making it work well? What's not? Of course, there are also the technical issues and concerns—is it working well for doctors, hospitals, plans, I guess drug companies now?—but really, my North Star is the people who are served by the program.

Today there's 68 million people. We think of it as a program just for seniors, but it also covers close to 10 million people who are under age 65 with permanent disabilities. It's a mixed population. If you look on TV, you see healthy, wealthy golfers and all the TV ads for Medicare Advantage plans. But the truth is, while some are healthy and wealthy, many people have serious needs—cognitive, physical, economic hardship. For the program to succeed, it needs to succeed for all. And that's really been the thing that I care the most about.

The Mission and Impact of KFF

Tricia, maybe you could tell us a little bit more about KFF and how it interacts with providing policy guidance around Medicare.

KFF as an organization, as you said earlier, is nonpartisan. Our mission is to provide timely information and analysis in real time to inform teams. What we try to do is anticipate what information policymakers are going to need to inform their decisions. The policy group of KFF, which I'm a part of, is always thinking about what data point, what "killer finding" we call it sometimes, will help them understand the impact of a policy. So we do research, we do polling, and we also have a news service, KFF Health News. But we all have the same purpose. We're all about providing information to various audiences so people who rely on facts and data can have what they need to make tough decisions.

I would just say as a call out, too—and I think already, given the long history of the organization and the quality of work you do, this is no secret to a lot of people in the US healthcare system—but that notwithstanding, I personally consider the work that you all do and the reports that you put out required reading. I would put a plug in for people to really follow the work you do because I don't know if you have a parallel in terms of the quality of what you put out.

One of the things that I find most gratifying is when I go out and I'm speaking or I'm teaching, or even when we're hiring people, what we often hear is, "I don't think I could have gotten through graduate school without KFF. I use your material all the time." We hear that from different types of people depending on their professions. And that makes us all feel great because we feel like the work that we're doing is super important. That's true also among policymakers, Democrats and Republicans. We often hear, "Oh, yeah, that KFF study really influenced my thinking on something." That's kind of what it's all about.

And in full disclosure to all our listeners, we use KFF a lot to prep for our podcast, and I quote you extensively as well. So we ourselves are big, big fans.

Happy to hear it.

Traditional Medicare vs. Medicare Advantage

So I wanted to shift a little bit to talk about the current state of Medicare. We know that there's about 66 million Medicare beneficiaries in 2025, and over 50% now are enrolled in Medicare Advantage. The Part A trust fund may be projected to be insolvent by 2036, though new projections may be shifting that slightly. Physician payments have lagged inflation by almost 26% since 2001, according to MedPAC. I guess my question to you is: what's underappreciated about how traditional Medicare is holding up, and where is it falling behind its private MA counterpart?

That's a lot to pack in a question. I actually think traditional Medicare has not gotten the attention that it deserves. In the past really more than a decade, Medicare Advantage has been the shiny nickel. People talk about Medicare Advantage, people see advertising for Medicare Advantage. You don't see advertising for traditional Medicare. And for a variety of reasons, Medicare Advantage offers all these benefits that are really appealing to people, particularly those who live on fixed incomes, but nobody talks about the trade-offs.

There's a lot of defense of the Medicare Advantage program and a strong lobbying effort to sustain it in its current form or grow it, but less so for traditional Medicare. As you pointed out, we have reached the tipping point. We have exceeded the tipping point. We are close to 55% of all people on Medicare in a Medicare Advantage plan. In many communities across the country, it's more like 70% or 80%.

This is something worthy of policy attention. But I have to say, other than some consumer protections, a little bit about supplemental benefits, and some stuff at the regulatory level, Congress really has not wanted to touch payment issues or get too involved in Medicare Advantage. What's happened is in some ways traditional Medicare is like the stepsister that hasn't gotten the attention from Congress.

A small example that I tell people and they ask, "How's that even possible?" Every health insurance plan out there, virtually every one, has an out-of-pocket limit. All Medicare Advantage plans are required to have an out-of-pocket limit. Traditional Medicare doesn't. That just seems anachronistic. That really is not keeping up with what people understand to be a model of what health insurance should look like. Yet there's just not a lot of attention given to what traditional Medicare should look like and what benefits need to evolve.

That's also true to some extent with payments. You mentioned physician payments. That's a real issue. I know the physician community has been working this issue and Congress still hasn't addressed it. But I wonder about the future of traditional Medicare. I do think that Medicare is on the path to privatization. This really matters for hospitals, for physicians, for patients. One of the things that's so interesting about how the Medicare Advantage program has evolved is that it's really, from the perspective of societal costs or cost to the federal government, more expensive than the traditional Medicare program.

Of course, that was difficult to foresee at the origin because as I understand it, it was meant to be really a minority, niche program for some segment of the senior population, not more than 50 or 70 or 80 percent like it is in some geographies.

You were just talking about when I first started working on Medicare issues, it really was like this small part of the program. Maybe 5% of all people in Medicare were in a Medicare Advantage plan. Enrollment grew slowly, but it really took off particularly when the drug benefit was enacted and there was a focus on private plans. It has just grown so rapidly since then.

Impact of Social Security Administration Cuts on Medicare

Another thing I wanted to ask you about—I think it was something that KFF put out that sort of turned me onto this idea—is that cuts to the Social Security Administration and to staff out in the field and the Social Security offices may also have an impact on the Medicare program. Right, because those folks help seniors actually sign up for the program. Correct?

That's exactly right. So that's sort of a new thing we are paying attention to. Social Security helps make Medicare work. Medicare doesn't have a presence in local communities where people can go and ask questions, find out about whether it's time to sign up for Part B, how to sign up for Part B, or how to get low-income subsidies under Part D. This is the front-facing part of the federal government where people can go and ask questions and figure out the consequences of delayed enrollment.

If Social Security offices evaporate in communities, people are going to be left high and dry. They're going to make mistakes. Medicare has already become so complicated. I think we are all seeing that if you all have family members who are going on Medicare. It used to be that people just went on Medicare and they were done with it. But now they turn 65, and I remember my sister called me and said, "Wait, I need A, I need B, I need D." And then I told her she needed a Medigap plan and I need G. She asked, "Are you kidding me? What is this?"

She wasn't the only person to do that. I have a lot of friends and family members who are going on Medicare and it's pretty easy to trip up. People don't understand the trade-offs in making different decisions. Social Security at least helps with the enrollment part, and that's a very important function. It also helps with Medicare Part D low-income subsidies. So if Social Security cuts staff considerably, even if the offices stay open, there are real concerns about who will be available to help the large number of people who age onto Medicare each year.

Medicare Advantage Costs and Payment Reform

You brought up the Part D program, and I want to ask you a question about that in just a moment. But before we do that, just to add some precision to that comment about Medicare Advantage being more expensive than the traditional program—if my figures are correct, in 2024 it was $83 billion more than if those same patients were actually in the traditional Medicare program. Which just happens to be—chip on the shoulder of a physician here—more than the Medicare spend on physicians. That $83 billion. Unbelievable, right?

Exactly right. Medicare pays on average 20% more per person who enrolls in a Medicare Advantage plan than it would pay for similar people in traditional Medicare. That comes from MedPAC. They do this analysis every year, but that number was kind of a stunning number when they published it.

What's interesting to me is Congress is right now looking for savings to help offset the tax cuts, but they're not really looking to the Medicare program. They're looking to the Medicaid program, which maybe has some savings there, but there are clearly some savings that could happen that could be at least examined from the Medicare program. The increase in higher payments associated with Medicare Advantage isn't necessarily seen directly by beneficiaries, but in fact, they're paying for these higher payments because Medicare beneficiaries pay Part B premiums that are directly affected by the growth in spending for the Part B side of the program. That helps to pay for Medicare Advantage. So people in the program are paying for Medicare Advantage plans to receive relatively high payments. And I think we have shown, and others have too, that Medicare Advantage is a relatively profitable market.

So premiums go up and there is some concern that this also affects the Medicare trust fund.

Prior Authorization and Consumer Protections

Absolutely. And along these lines of Medicare Advantage, you and I had actually met originally on a panel about some of the concerns around Medicare Advantage, particularly around prior authorization. But there's many other concerns our viewers and listeners are very well aware of around risk coding intensity, upcoding incentives, and star rating manipulation. MedPAC and CMS have floated some payment reform ideas, risk adjustment calibration, and potential limits on MA broker incentives. If you had to redesign the Medicare Advantage system, what would be the first lever you'd pull to try to get it back in shape?

Well, there are a number of proposals that have been put out there to try to—I don't want to say equalize or even level the playing field—but there are a number of ways to make Medicare Advantage operate more efficiently, and I think a number of those ideas could be considered. As I said earlier, the issue is they're not really being talked about, and even the consumer protections are not really front and center.

Earlier last year, we put out a paper that talked about gaps in what we know about Medicare Advantage. There is some basic information that researchers don't know, doctors don't know, and consumers don't know. You and I were on a panel talking about prior authorization. Wouldn't it be great if we knew whether some insurers impose prior authorization requirements more than others? Probably patients would want to know that. Doctors would probably start to advise patients as a result of that.

Wouldn't we want to know denials by service? If you're a cancer patient or you can anticipate some type of service you might need—you're going to get a hip replacement next year—and you're in a plan that has a lot of prior authorization requirements for skilled nursing facilities and denials, you might want to choose another plan. But beneficiaries don't have that information. They don't have information because it's not collected and reported about supplemental benefits in any kind of detail to make decisions.

Very true. And the asymmetry of information the beneficiaries have has led to these disparities in care. The people who oftentimes are enrolled on Medicare Advantage are disproportionately lower income than some of those on traditional Medicare.

That's true. I don't know if that will continue to be true, but we've done focus groups and we've talked to people and told them about some trade-offs. A big trade-off is provider networks. You sign up and they change from year to year, and people don't actually get the information they need to know whether they should switch plans to stay with their doctors. That is a real worry. That's a real problem.

And we're in this period now where the rule which is supposed to start in 2026 to provide further consumer protections and put greater limits to certain activities that the Medicare Advantage plans are able to do. But the question remains with the devil's in the details and how operationalizable those rules are going to be, or is it going to be easy for the commercials who operate a Medicare Advantage space to do whatever they want? And so that remains to be seen in 2025 because of course, we haven't gone live with that yet.

I think there are other questions. I will say the Biden administration did put in new reporting requirements that should make it a lot easier to see what plans are spending, for example, on supplemental benefits, how many beneficiaries are using these benefits, whether higher-income beneficiaries within plans use benefits more than lower-income, and whether there are differences by race and ethnicity. That would all be great to know.

There's also that policy that I think is really helpful for consumers, which should start in 2026, telling people mid-year: "You know what? You've got a dental benefit offered to you that you haven't used. You can still get $1,000 worth of dental care under your plan." That would help people maximize the benefit that they may not really understand that they have.

So a question I have is: will the new administration enforce these new data requirements, enforce these new consumer protections? Will they roll them back, and what else might they put in place? I think that's what we'll just have to watch and see.

Drug Price Negotiations and the Inflation Reduction Act

It is a great question. And I wonder if we may see rollback on some of the provisions that also came from the Biden administration as it relates to the Part D program. I'm talking specifically about the out-of-pocket yearly max drug price negotiations as well for things like Eliquis, Jardiance, Xarelto—drugs like that. We know that especially from the work you all have done at KFF, there is strong bipartisan support for these protections for seniors. But on the other side of the coin, there is strong pharma pushback to extending these measures further. I would be interested to hear your thoughts on what direction you think it's going to go. Are we going to continue on this tack of greater protections and maintaining these out-of-pocket limits, or see rollbacks in the opposite direction?

The out-of-pocket limit—there's a $2,000 out-of-pocket limit on outpatient prescription drugs. That's a phenomenal benefit and most people don't know about it. So I'm just glad that you even mentioned it. I think that's here to stay in part because the pharmaceutical industry supports it and people like it. It's something that saves money for people. It doesn't really do anything but affect drug prices. So it's popular. I think caps on insulin costs also will stay. Also popular.

There is a question about negotiations. Right now under the Inflation Reduction Act, the federal government has authority and is required to negotiate the price of prescription drugs for Medicare. That was hugely controversial. As you said, the drug industry pushed hard against it. I don't know that it will be repealed. It would take an act of Congress to repeal it. It has already taken effect and it is rolling out, and they are continuing to roll it out each year. The number of drugs subject to negotiation is cumulative. So that will continue to increase.

But there is the possibility that Congress or the administration will take steps to weaken the law. For example, there is a bill that could potentially be integrated in the budget bill, the reconciliation bill that's being negotiated, that would give drug companies more years to set their prices before they would be eligible for negotiation. Right now they have a seven-year period where they can set their prices before they can be picked from a list as drugs that could be negotiated. There is interest in extending that for up to 11 years. Sometimes people refer to that as the "pill penalty."

The pill penalty?

Yes, pill penalty. That's kind of the shorthand. So that's an example of a change that would weaken the law. It would cost money, but there is strong push from the pharmaceutical industry to see if they can get that through this year. There may also be interest in broadening the exemption for orphan drugs. These are drugs that a relatively small number of people take but are necessary for those small number of people. There has been interest in the past for broadening the definition of what qualifies as an orphan drug, so that could be in there.

And then there's been a lot of chatter in this past week about all sorts of other proposals that could either go in the reconciliation bill, or discussion earlier today about the Trump administration having a new executive order that would put in place "most favored nation" type policies that would apply to Medicare and Medicaid. So this is a very rapidly moving stage. And that's why when you say, "Do you see things rolling back?" Possibly, but I could also see some effort moving forward.

During the first Trump administration, there were a lot of ideas that were floated. Almost none of them actually took effect, but there was at least a lot of conversation about doing something about drug prices. So it's hard to predict where this will go. And then there's also other questions about tariffs that apply to pharmaceutical companies and what that all will mean, and will there be shortages in this country?

And the idea of shortages is pretty scary for nations. If I could just make a logistical point for our listeners, and we talked about this before we started the session, is that we are recording this episode on the evening of the 7th of May, which is before the reconciliation process starts next week. Tricia has made reference to that several times. A lot of things are on the table next week, including Medicaid, and that's been in the news quite a lot. And if it's okay with Tricia, maybe we could talk a little bit more about that at this point.

Proposed Medicaid Cuts and Economic Implications

That's exactly where I wanted us to pivot to. So let's get into Medicaid. What do you think is the likelihood of actual cuts to Medicaid with the GOP Congress and the Trump administration? You mentioned there's bipartisan support to not cut Medicaid, and there's been a lot of data published on that. So how realistic is this and why are they pursuing it?

I can answer the second question first, which is: they are pursuing cuts in spending in order to help pay for the tax cut, which is like $4 trillion or something to that effect. The Medicaid number is $880 billion. It's really controversial. The president has not been all in on supporting House Republicans in enacting Medicaid cuts. There is sort of this conversation about, "Well, it'll be okay if it's not a cut in benefits, if it goes after fraud, waste and abuse." But there are differing views on what that actually means.

The Congressional Budget Office just came out today with information that helps lay out how almost any idea that they've been talking about will lead to more people who are uninsured. We've done a fair amount of work to show how hospitals rely so heavily on Medicaid. Medicaid is 20% of all spending nationwide on hospitals. So a significant cut to Medicaid along the lines of what they're talking about will have serious ripple effects across the country if it's enacted. It certainly will affect hospitals, it also will affect nursing homes—which is a whole other topic—and if it affects hospitals, that's going to affect local economies because hospitals are such a major employer in markets across the country.

So it's really a big deal. Our polling and polling of many others indicates that the public is not supportive of Medicaid cuts. And as you said, that's Democrats and Republicans. If you call it "fraud, waste and abuse," it sounds a little bit better. But if you play it out and say, "Well, this policy that you're describing as fraud, waste and abuse is actually a way of raising money in order to pay for benefits and coverage," then I'm not sure the public's going to be so supportive.

Medicaid Work Requirements and Administrative Burdens

I was wondering, has KFF come out with any data around this proposed work requirement with Medicaid and how does that poll?

The problem is polling is a little bit different. I think people like the idea that people should be working, so that polls well. But the truth is, most people on Medicaid—when you take away older people who have Medicare and Medicaid—have a connection to the workforce. Or they have a disability or they are caring for a family member. So it's really a very small segment of the Medicaid population that is not working and doesn't fall into one of these other buckets.

But if you impose work requirements and you impose administrative requirements to prove that you have a connection to the workforce or that you are exempt for certain reasons, you're putting an enormous burden not only on all the millions of people who rely on Medicaid, but also on states that will have to document this. That's a huge cost to the states. And there's a great risk that people will fall between the cracks.

If you make it hard for people to stay on their coverage, people will fall through the cracks. More people will be uninsured. That's why those of us who are fortunate have automatic pension systems, right? We make it easy for people to do the thing that is in their own best interest. Work requirement documentation or redetermination of eligibility makes it harder for people. And if you have to do it in person, you can just imagine: "Okay, I got to leave my job to prove that I'm working. I've got to take two buses to get to an office. I don't have a copier at home to copy papers." It's just enormously burdensome. But to your point, it polls well.

And it's interesting you brought up the administrative costs associated, because on the one hand, there's staffing cuts to some of these agencies, and on the other hand, increasing administrative burden. It doesn't seem like rationally it makes sense for it to work so well.

The other thing that's going on in the broader framework is the administration is trying to scale back the role of the federal government. In scaling back the role of the federal government, either the services evaporate or it puts more fiscal pressure on states because states are the ones that are going to have to pick up the slack. And if states are picking up the slack because federal spending on various programs is going down, that jeopardizes the ability of the states to invest in other things than they normally would invest in.

The interesting thing here, if I could just make a basic economics point, is that having a GDP that is not shrinking is generally the objective of federal governments. Because obviously if you're in recession, GDP gets smaller, that gets pinned on you. The amount of cuts to government spending—a major component of GDP—that are on the table here... I don't think there's any serious economist who thinks that the US economy is in a position from the private sector to accelerate beyond those cuts to then have the math work out that we actually have a growing economy. The tax cuts would have to be so large that they would have to outrun the tariffs and outrun these government spending cuts in order to have GDP growth. And it makes you think that a prolonged recession would be the likely outcome if we did pursue this policy approach to its natural conclusion.

The other thing I was thinking about is that while there will be most likely tax cuts at the federal level, to the extent that this shifts obligations to states, states are going to consider tax increases, right? The money has to come from somewhere unless fewer people get benefits or the people who get benefits get a lot less. So in a sort of zero-sum game, if you don't want to cut people or benefits, money has to come from somewhere.

State-Level Disparities in Medicaid Coverage

Just one last thing along this line of conversation—it's always struck me as sort of awkward and not a great service to the citizenry of the United States to have the experience of seeking or enrolling in government programs be so vastly different state to state. I'm talking about if we had a Medicaid work requirement, the ability of state X to enact the program and run it efficiently would be vastly different from the state right next to it. That would produce a very different experience for beneficiaries on one side of the border versus the other. And the extent to which the Medicaid program in a given state is funded by the amount that a given state pulls down in federal money is so vastly different. So if there is a significant Medicaid cut enacted, the experience of being on Medicaid will be substantially different from state to state, even more different than it is right now. Does that track with your thinking and your analysis on this, Tricia?

I think that's completely right. As you said, the experience of being on Medicaid does differ from state to state. Eligibility differs, benefits differ. There is sort of a commonality across states, but beyond that there is variation. But if you now impose upon that the changes that are being talked about, you can imagine those differences being exacerbated quite a bit.

And unfortunately there's the economic component, but then there's obviously the political component, and different states obviously have different politics and vested interests to remain in power. So it's not necessarily always what's best for its citizenry. If you think back to even what happened when the exchanges were created under Obamacare as an example of how all that played out state to state, and how it took several years for some of these states to catch up once the politics was out of the way. I mean, the Medicaid expansion—there are states that still haven't done the Medicaid expansion.

Yes. That's incredible. Is it about six or seven at this point?

About 10.

Cuts to Community Living and Support Programs

Speaking of cuts, we hit on cuts to the Social Security Administration, and we're hitting on proposed cuts to Medicaid. Once again, just regarding the quality of the work you all do, I wanted to point out something else that I wouldn't otherwise have known about if it weren't for KFF: cuts to a little-known program called the Administration for Community Living. I wanted to call that out, Tricia, because I know you've commented on this and written about it. Can you explain the impact of that program? Because a lot of folks don't even know what it is.

So this is an administration within HHS that manages the whole idea that we've got a lot of programs out there that help older people, but there's not a place within the government where it's coordinated. This is an office within the Department of Health and Human Services that oversees, for example, the Older Americans Act and programs that you've probably never heard of that are supported by the Older Americans Act—caregiver support, support for people with elder abuse issues, transportation, home-delivered meals. It's an array of services that help people piece it together.

It's not at all clear what the future of the Older Americans Act will be. Right now it exists, but there has been talk about eroding programs under the Older Americans Act. And the Administration for Community Living itself may be disappearing under the reorganization within HHS, which means some of the functions that it does will move to other parts of the Department of Health and Human Services. Some things are moving to the Centers for Medicare & Medicaid Services, for example.

A program that also is on the line for cuts is what's called the SHIPs—State Health Insurance Assistance Programs. This is the only independent, nonpartisan, objective, not financially invested source of information for people who are making Medicare coverage decisions. It's mostly staffed by volunteers. It's really understaffed and under-resourced. And it's one of the areas that is subject to cuts that's sort of managed by the Administration for Community Living. That function is going to the Centers for Medicare & Medicaid Services.

But it's not clear that the people who oversee these programs are still employed because several of them have lost their positions, or they may not be going to the place where they will have responsibility for administering the programs that they've been guardians of for the past several years. Some other functions are going to what's called ASPE, the Assistant Secretary for Planning and Evaluation. Their shop has been greatly reduced from like 160 to 40 people. So the function is moving. It's possible that the efficiencies will materialize and services will continue to be provided. But there's also some risk when you move around the chairs on the deck that there will be some chairs that fall off the ship. And I think that's the real worry.

Plus, with fewer people to manage these programs, the people who are left are going to be moving to different places where they may or may not have the infrastructure to manage these programs for older adults. And then there's also the potential for budget cuts that will slash the budget of these programs.

These seemingly small programs, as you said, really help people piece it together. Both Amar and I have talked about this for his patient population and mine. We have so many of the folks we take care of who take advantage of these services. There's a future episode we're planning about philanthropy and the role it plays in filling these gaps.

Challenges in Long-Term Care and Aging Support

There is a real question here. This is actually a much bigger question and a topic for you to do in another podcast. Our country really has not embraced in a meaningful way what we're doing about long-term services and supports for an older population. We have an aging population. We don't really have a program other than Medicaid that helps pay for nursing home and home care services. All these middle-income families are spending down vast amounts of money to get the supports that they need in order to function relatively independently at home. We don't have a financing system, and families are going broke trying to figure out how to piece it together. There's also no information about where do I go to get help?

Another topic for you to tackle: it's immigrants in our country who have really bolstered the long-term care system. These are people who are providing care—presumably documented people, I really don't know—but this is a population that's keeping older people safe either in nursing homes or in their own homes. At some point we need to have a national discussion about that because without that workforce, who's going to do it?

You're very astute to point out the issues surrounding elderly care, particularly at the home health level. We did an episode on home healthcare with a physician innovator who was building a startup around that, but he's in Canada.

Too bad.

It did span both countries, his business. But since we're going toward the close here, I wanted to go back to KFF and some of the tools you provide. We talked about how your policy work is cited tremendously. Some of the other tools KFF produces include Medicare spending calculators, subsidy eligibility tools, Medicare Part B and Part D cost comparison sheets. Given that you guys have some of the best tools out there, what do you see as the most important contribution of KFF for now and going forward?

Essential KFF Tools and Resources

That's a tough one. What we do is we sit every day and ask, "What do people need to make decisions?" So some days it's a poll, some days it's a calculator, some days it's a hot news story. Our news service broke the story about Social Security clawing back disability payments. So it really can be different things at different times. Sometimes it's just basic facts. We are always surprised that people just need basic facts. We have state health facts now, and we do a ton by congressional district. You have to create different things for different audiences, so I don't think I have a favorite child. You have to be a jack of all trades.

But I will tell you a new thing we did this year: it's our Health Policy 101. This is targeted for students, but really it's great for reporters. It's great for anybody who wants to skim something quickly and know just enough to be dangerous, but also just know enough to kind of get through on a news topic.

Hopefully maybe you could plug this podcast in that Health Policy 101. We try to educate people around some of those topics as well.

I think it's great that you're reaching perhaps a different audience than we do. It's important that the physician community and the hospital community engage on issues, not just issues that affect them directly like "are we going to get a bump in the physician payments?" You are on the ground. You know how things are affecting your patients. When we were on a panel together, I heard you loud and clear talking about some of the struggles your patients are having. Members of Congress need to know that. Reporters need to know that. Your voice matters.

Advocacy Strategies for Clinicians and Health Systems

You were talking a lot about advocacy, and I think that's a good place to end. How do you think clinicians and health systems should approach engaging around Medicare reform? What is a practical, actionable approach?

As I said, you are on the front line. You do see things that are happening to your patients or yourselves that are super frustrating, or maybe great, but that information doesn't necessarily flow to Washington. I think you can't talk about everything, but having a list of things that you really like to see done is important. It could be "my patients are struggling with the cost of their medicine, and I'd really like to weigh in on that issue." It could be "Medicare Advantage prior authorizations are just killing us; they're taking so much time, we want to take action there." Obviously physician payments.

But explaining to your member of Congress at home, not necessarily in Washington, pick your spots. You can't do everything, but explaining what's really happening on the ground matters. The hospitals have been doing that more and more on Medicare Advantage and Medicaid cuts. They have a presence right now, particularly lobbying heavily on Medicaid in Washington. But where you can have a big impact is talking to your member of Congress at home. Go to a town meeting, set up a meeting in his or her office. That's where you can make your mark: tell a story and bring a binder of KFF material to support it. That's what it is. Tell a story and have a number.

Conclusion

Tricia, thank you so much for this round robin of the key issues that you're looking at from your analysis at KFF. This has been a real treat for us. This is a really exciting period for the show, and so we thank you for being on.

Thank you very much. Such a pleasure. And it's been fun talking to you both.