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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 ImagesThat 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.
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