Medicare red tape turned insurers into villains



Imagine your doctor diagnoses you with Alzheimer’s disease, evaluates your needs and risks, and recommends a tailored treatment plan to extend your healthy years. Who should have the final say over whether you pursue that care: you, your family, and your doctor — or an insurance company that has never met you?

For most Americans, the answer is obvious. Doctors and patients should make care decisions.

If policymakers want fewer insurance denials, they should stop creating incentives for them.

Yet in many cases, insurers end up with the final say.

New polling from Market Institute and President Trump’s pollster Fabrizio Ward found that 89% of registered voters believe doctors often choose not to prescribe Alzheimer’s tests or treatments because they know insurers are unlikely to cover them and patients cannot afford to pay out of pocket.

Voters are recognizing a real trend. Alzheimer’s patients have made headlines for benefiting from new treatments, only to receive abrupt coverage denials from their insurance companies.

Treatment allowed one patient, Lori Baetz, to return to her daily routine. When coverage was pulled back, she deteriorated, even getting lost in her own neighborhood. Lori’s neurologist, Dr. Cara Leahy, wrote that her patients are repeatedly denied coverage. Similar denials are happening across the country, including in New Jersey and North Carolina, and across insurers.

Thousands of Americans find these delays and denials unjust. In fact, a shocking 41% of young Americans said the murder of UnitedHealthcare CEO Brian Thompson was “acceptable.” One voter from a Market Institute focus group said of insurance companies, “They just want to wear you down ... so you just give up.”

Americans’ frustration is understandable. But insurance companies are often following rules set by the federal government.

The real culprits are the behind-the-scenes government policies that encourage insurers to delay and deny coverage.

The clearest example is a Biden-era Medicare policy known as Coverage with Evidence Development.

After the Food and Drug Administration approved a new generation of Alzheimer’s therapies, the Centers for Medicare and Medicaid Services took the unprecedented step of limiting Medicare coverage unless patients participated in government-approved studies and met additional requirements.

RELATED: Trump DOJ charges 455 people allegedly tied to $6.5B in health care fraud

Feodora Chiosea/iStock/Getty Images

That created a second layer of red tape after the FDA had already deemed the therapies safe and effective.

The decision sent a powerful signal throughout the health care system. When Medicare, the nation’s largest health care payer, treats FDA approval as insufficient, private insurers follow.

When Lori’s coverage was denied despite her positive response to treatment, the company described the therapy as “investigational/experimental,” even though the FDA had approved it. The company was following Medicare’s lead. When Medicare treats approved therapies as experimental by requiring additional paperwork and registration, insurers can cite the government’s own policy when denying coverage.

That bad policy worsens the financial and human cost of Alzheimer’s disease.

The lifetime cost of caring for a person with Alzheimer’s exceeds $400,000, with families shouldering roughly 70% of that burden through unpaid caregiving and out-of-pocket expenses.

Meanwhile, Medicare spends roughly $174 billion annually on Alzheimer’s patients, while Medicaid spends another $72 billion, much of it on long-term care. As Alzheimer’s cases double over the next few decades, those costs will continue to climb.

The good news is that treatment could help curb those mounting costs by keeping Americans independent and in the workforce longer.

According to USC Schaeffer research, providing treatment before symptoms fully emerge could add a full year of life, reduce nursing home stays by nearly two years, and lower medical spending by roughly $48,000 per patient. That means more Americans remaining independent, fewer families crushed by caregiving burdens, and more workers preserving their economic productivity.

Every patient who remains independent, stays out of a nursing home, or delays the need for full-time care represents both a human victory and an economic one.

If policymakers want fewer insurance denials, they should stop creating incentives for them.

The FDA is charged with determining whether a therapy is safe and effective. Once it does, CMS should not erect a second regulatory barrier that encourages insurers to do the same.

Until that changes, Americans will continue blaming insurance companies for behavior government policy encourages.

Democrats’ ‘Fix’ For A $5 Trillion Medicare Spending Increase Is The Same Proposals That Caused It

At a time when multiple budget analysts have highlighted an explosion in Medicare spending due to the IRA, what did Wyden’s white paper propose? More of the same.

Trump DOJ charges 455 people allegedly tied to $6.5B in health care fraud



The Department of Justice on Tuesday unveiled the results of the 2026 National Health Care Fraud Takedown, which resulted in criminal and civil charges against hundreds of defendants and billions in allegedly stolen taxpayer funds.

The enforcement effort involved 56 federal districts, 45 U.S. states and territories, and 455 defendants, including 90 doctors and other medical professionals, tied to more than $6.5 billion in alleged fraud.

'The government seized over $30 million in bank accounts, a $594,000 Ferrari 296 GTS, seven other high-end vehicles, an $865,000 custom Bulgari necklace, and $1 million worth of other luxury jewelry.'

The DOJ accused the defendants of participating in numerous schemes, including opioid abuse, submitting false claims to Medicare and Medicaid, and causing patient harm, including death. The department also claimed that 10.7 million pills of controlled substances were illegally distributed.

The alleged stolen taxpayer funds were used to purchase high-end vehicles, jewelry, and real estate, among other luxury items. The federal government has seized $182 million in cash and other assets.

“This announcement marks the greatest combined federal and state effort in combating health care fraud in history,” acting Attorney General Todd Blanche stated. “This team is working tirelessly to take down fraudsters who steal from taxpayer funded programs and prey on vulnerable Americans.”

The DOJ highlighted that charges were filed against 11 individuals allegedly tied to billions of dollars in fraudulent claims for amniotic wound allografts, a wound treatment made from donated placental tissue typically used to repair hard-to-heal injuries.

RELATED: Trump DOJ charges illegal aliens in Boston with nearly $1.5 million in welfare fraud

Image source: Department of Justice

In the District of Arizona, the vice president of sales for a company was charged in an alleged kickback scheme after providers allegedly billed Medicare over $4 billion from Dec. 2021 to June 2024 for his company’s allografts.

“The company did not manufacture allografts and instead acquired allografts from tissue banks and relabeled them for sale at a 2,000% mark-up, charging up to $1,450 per square centimeter,” the DOJ stated.

The defendant and others allegedly targeted hospice patients to apply allografts to superficial wounds and treat areas that exceeded the size of the wound.

The defendant was accused of receiving $24 million from the company and spending the funds on “multi-million-dollar houses, million-dollar life insurance policies, luxury vehicles, including a $135,000 Maserati, and luxury watches.”

RELATED: JD Vance is ending the Medicaid gravy train

Bulgari necklace and beach resort in the Philippines. Image source: Department of Justice

In the Southern District of Texas, the DOJ also charged a nurse practitioner who allegedly billed Medicare $906 million for medically unnecessary allografts.

“As alleged, the defendant used the fraud proceeds to purchase high-end vehicles, real estate, and luxury jewelry, and to fund the construction of a $4.6 million ... beach resort in the Philippines,” the DOJ stated. “The government seized over $30 million in bank accounts, a $594,000 Ferrari 296 GTS, seven other high-end vehicles, an $865,000 custom Bulgari necklace, and $1 million worth of other luxury jewelry.”

The DOJ reported that Medicare claims for allografts skyrocketed from $1.2 billion in 2022 to $14.4 billion in 2025.

Like Blaze News? Bypass the censors, sign up for our newsletters, and get stories like this direct to your inbox. Sign up here!

The Social Security Crisis Is Even Worse Than We Thought

In avoiding political discomfort for decades, Congress and presidents have set the nation up for an economic and social catastrophe.

Big Medicine is about to make pregnancy more expensive



The American Medical Association is overhauling the way doctors bill for pregnancy care. Anyone who cares about families should be alarmed.

The AMA says the new model promotes accuracy and modern care. Nice slogan. For millions of American families already struggling with rising costs, it looks more like an unelected lobbying organization has found a way to make having children even more expensive.

Policymakers cannot allow the AMA to blow up the current system at the expense of families.

Starting January 1, 2027, the long-standing global maternity payment will be replaced with a more complicated system that bills pregnancy, labor, delivery, and postpartum care in pieces. Instead of treating pregnancy as a single episode of care, the new structure lets providers bill separately for visits and services.

But pregnancy is not a menu where mothers pick one item from column A and one from column B. It is a coordinated journey that should be managed as a whole. A bundled payment system rewards providers for delivering care efficiently and effectively. An unbundled framework rewards the accumulation of billable moments.

For many couples, the question is no longer whether they want children. It is whether they can afford them. Now one of the most expensive moments in family life could become even more expensive.

The AMA controls the billing codes — those five-digit numbers patients see on medical receipts. The codes tell insurance companies what providers did so they can get paid. Moving pregnancy from one bundled code to many separate codes pushes maternity care toward a fee-for-service model. That model incentivizes more services and more fees.

Federal watchdogs have warned for years that fragmented billing creates openings for abuse. The Department of Health and Human Services Office of Inspector General investigates billing practices and often identifies coding and billing integrity problems.

In one audit, the inspector general found that Medicare made up to $17.8 million in potentially improper payments tied to complicated coding and other billing problems in opioid treatment programs. Different specialty. Same lesson. When payment systems get sliced up or loosely controlled, waste, fraud, and abuse follow.

RELATED: The right to life cannot depend on a baby’s zip code

Kevin Dietsch/Getty Images

Pregnant women and their families get stuck with the bill. Patient advocates already warn that the new system could mean higher out-of-pocket costs.

Policymakers moved toward bundled payments for maternity care because the model had the potential to lower costs and improve quality. Bundling can discourage unnecessary cesarean sections, which cost significantly more than vaginal births, carry greater risks for mothers and babies, and require longer recovery times.

When payment incentives reward more services rather than better outcomes, families can face higher medical bills, extra recovery time, more follow-up visits, and increased child-care costs.

The policy question is not whether every provider will abuse the system. It is whether Washington should allow a system that makes abuse easier and family life more expensive.

This billing-code change is landing at exactly the wrong moment. The United States recorded its lowest fertility rate ever in 2024. If conservative policymakers are serious about family formation, they should not tolerate the AMA worsening one of the most expensive and stressful experiences in American life.

As the father of a large family, I know firsthand that having children in America is not for the faint of heart. Every new baby is a blessing. Every parent also knows the bills come fast.

Policymakers cannot allow the AMA to blow up the current system at the expense of families. American families will notice when the bills multiply and the care journey is less coordinated. We cannot allow another elite institution to call this progress while ordinary Americans pay more for the privilege of bringing a child into the world and pursuing the American dream.

The Bill For Medicare Insolvency Is Coming Due, And It’s Not Pretty

The Social Security and Medicare trust funds incurred a net of over $132 billion in losses in 2025 — losses that will only grow in future years.

JD Vance is ending the Medicaid gravy train



The Centers for Medicare and Medicaid Services may have just signaled the beginning of the end for one of California’s most aggressive Medicaid financing schemes.

In late May, CMS proposed a rule that would limit many Medicaid payment arrangements to Medicare-equivalent reimbursement levels while targeting the financing mechanisms that shift excessive costs onto federal taxpayers.

The more states spend, the more federal money they receive.

The proposal specifically highlights intergovernmental transfers and similar arrangements that have allowed states to inflate federal reimbursement claims.

This rule comes as California health officials are asking CMS to approve a set of pending state plan amendments that would further expand reimbursement arrangements built around intergovernmental transfers — the very type of financing mechanism now facing increased scrutiny from federal regulators.

For years, states have exploited these loopholes in Medicaid’s financing rules to draw down more money from Washington. CMS now appears ready to put some limits on that practice.

Vice President JD Vance and CMS Administrator Mehmet Oz deserve credit for cracking down on these kinds of abuses. Vance said the administration is withholding $1.3 billion in Medicaid reimbursements from California because the state does “not take Medicaid fraud very seriously.”

Oz warned that states have exploited “the cracks and crevices” between state and federal systems — describing California as a member of the “varsity team” of fraud alongside Massachusetts and New York.

The proposed rule makes the fate of California’s pending SPAs clear: They cannot survive. Approving them would directly contradict a rule CMS has already put forward, expanding the exact reimbursement scheme the agency has identified as a threat to Medicaid program integrity.

The only question now is whether CMS will formalize what its own rulemaking has already decided.

At the center of the IGT problem is Medicaid’s open-ended reimbursement structure. States spend money, and the federal government reimburses a percentage of those expenditures. Public entities recycle funds through multiple agencies to trigger larger federal Medicaid matching payments.

The more states spend, the more federal money they receive.

These arrangements may technically comply with federal rules, but they function as financial engineering schemes rather than legitimate health care financing. Medicaid was designed to fund health care for vulnerable Americans, not maximize revenue for governments and health care bureaucracies.

California’s ambulance reimbursement system provides a textbook example of the kind of payment arrangement CMS now appears determined to rein in.

RELATED: Trump’s next bill needs tax relief with teeth

Jim Lo Scalzo/EPA/Bloomberg/Getty Images

Under current rules, a public fire district can hold an emergency medical services franchise while subcontracting the actual ambulance operations to a private company.

Even though the private contractor performs the transport itself, the public entity can still bill Medi-Cal at the elevated IGT reimbursement rate — around $1,168 per transport in 2024, with a proposed increase to nearly $1,600.

If that same private ambulance provider billed Medi-Cal directly, that $1,600 would become roughly $339 under the standard fee schedule.

Federal taxpayers are therefore paying nearly five times the normal reimbursement rate for operationally identical services, simply because the billing structure has been routed through a government intermediary eligible for enhanced federal matching funds. For ACA expansion enrollees, a large share of Medi-Cal, Washington covers 90% of that already inflated cost.

The fire district keeps the difference between the inflated Medi-Cal reimbursement and the private contractor’s actual operating payment. Taxpayers finance the excess.

Unlike these existing payment arrangements that may eventually be required to conform to the new federal standards, California’s pending ambulance SPAs have not yet been approved. Federal regulators should not authorize an expansion of a reimbursement model they have already identified as inconsistent with Medicaid’s future direction.

CMS has now made clear that payment arrangements built around inflated reimbursement rates, intergovernmental transfers, and excessive federal matching dollars are no longer business as usual. States have been put on notice.

California’s pending ambulance SPAs should be among the first tests of whether the agency intends to enforce the principles it has now announced. If CMS truly believes Medicaid exists to fund patient care rather than reimbursement gamesmanship, these proposals should not survive review.

Democrats Object To New Medicaid Rule Requiring Able Adults To Work A Bare Minimum

The law should encourage able adults receiving taxpayer-funded benefits to contribute to the community while advancing their own self-sufficiency, and the new Medicaid rule does just that.

Ending Fraud Is Great But It’s Not Enough To Fix Medicare Insolvency

Washington policymakers can no longer ignore the mounting challenge of federal entitlements, especially Medicare.

Washington’s fraud machine needs handcuffs, not more hearings



Every government form I sign contains some variation of the same warning: “I certify that the information provided is true and correct.” “False statements may result in civil penalties.” “Federal charges may apply.”

I have been signing forms like that since Ronald Reagan was president.

Americans do not need another report telling them what everyone already knows. They need accountability.

For 40 years, I have managed a medical catastrophe. My wife has endured nearly 100 surgeries, multiple amputations, years of hospitalization, and enough insurance claims and medical bills to wallpaper a house. Over those four decades, I learned something millions of family caregivers understand all too well: You don’t respect what you don’t inspect.

Long before smartphones, electronic records, and artificial intelligence, I sat at kitchen tables with a pencil, a calculator, and a telephone, combing through Explanation of Benefits forms, hospital bills, physician statements, pharmacy charges, and insurance claims. I have argued with surgeons, hospital administrators, insurance executives, case managers, billing departments, and just about everyone in between. I have won all but two of those arguments because if I did not, my wife paid the price. The consequences of their mistakes landed in my living room.

When your loved one’s health and financial survival hang in the balance, you learn to confront, challenge, and stay in the room long after everyone else wishes you would leave. That is what advocates do. That is what skin in the game looks like.

Imagine if our elected advocates approached their responsibilities with even a fraction of that urgency.

As America approaches its 250th birthday, we are preparing celebrations, restoring monuments, and planning fireworks displays. That’s fine. I enjoy fireworks as much as anyone. But the colonists did not risk everything over fireworks. The Stamp Act was never merely about stamps. It was about accountability. It was about whether government could impose burdens on citizens while remaining insulated from the consequences of those burdens.

RELATED: Mercedes, Bentley, and McLaren cars seized in BUST of $30 million Medicaid fraud scheme, feds say

CHUYN/iStock/Getty Images

Two hundred and 50 years later, that question remains painfully relevant.

More than 65 million Americans serve as family caregivers. Together, they provide an estimated $1.2 trillion in unpaid care each year. They keep loved ones out of institutions, reduce burdens on taxpayers, and shoulder responsibilities that would overwhelm many public systems. We do not have lobbyists. We do not have communications directors. We have kitchen tables covered with bills. We have loved ones whose lives depend on us showing up again tomorrow.

Then, we turn on the news. We see stories of fraud. We see agencies unable to account for money. We see programs consuming billions with little to show for it but waste. We see officials preside over failure and retire comfortably while ordinary Americans are left holding the bill.

In “The Dark Knight,” the Joker tells Batman, “It’s all part of the plan.” After enough years of watching obvious failures produce little accountability, cynicism begins to sound less like paranoia and more like experience.

Finding fraud matters. But merely finding it is not enough.

If I discovered an error in a medical bill and nobody corrected it, the problem remained. If I identified the source of a problem and nobody addressed it, all I had really done was document my frustration. At some point, discovery without consequence becomes theater.

Americans have watched report after report, audit after audit, investigation after investigation. Fraud was found. Good. Now what?

Finding fraud is important. Arresting fraudsters is important. But accountability also requires asking who ignored it, who enabled it, who benefited from it, and who failed to stop it.

And if those people occupied positions of authority, what consequences do they face? Loss of office? Loss of contracts? Public accountability? Criminal prosecution where warranted? Or do they simply move on while the public absorbs the cost?

Otherwise, we’re not fixing a system. We’re simply rotating villains.

The average American lives under penalty of perjury. Every form I sign reminds me of it. If I knowingly misrepresent information, consequences follow. Why should the people entrusted with billions of taxpayer dollars operate under a lower standard than the citizens paying the bills?

If fraud occurred, prosecute the people responsible and name names. If someone knowingly violated the public trust, identify him and hold him accountable. Not for revenge. For stewardship.

I write this while undergoing cancer treatment. At the same time, I am still caring for a woman who has spent four decades battling catastrophic disability. If I sound impatient with waste, fraud, and excuses, it is because I have spent too much of my life paying for other people’s mistakes.

RELATED: Minnesota fraudsters fined millions of dollars — but report finds many don't pay and get released anyway

DNY59/iStock/Getty Images

Millions of caregivers know exactly what I mean. We are tired in a way that is difficult to explain to people who have never lived this life. Staying outraged takes more energy than most caregivers can afford. But we are paying attention.

Scripture says, “When the righteous increase, the people rejoice, but when the wicked rule, the people groan” (Proverbs 29:2).

There is a lot of groaning in this country. I hear it in hospital waiting rooms. I hear it in caregiver support groups. I hear it from people staring at medical bills long after midnight.

Americans do not need another report telling them what everyone already knows. They need accountability. They need leaders willing to impose upon government the same standards government imposes upon them.

For too long, the consequences of government failure have been borne by the wrong people. It is time for accountability to land somewhere else.