Your statement below sums this up very succinctly. Patients are taking a back seat; again….
“The court’s decision to grant temporary relief to insurers may preserve the “status quo” — but that status quo is one in which more than nine out of ten health plans in Texas were already failing to meet the state’s network adequacy standards. For patients in rural communities especially, that isn’t a status quo worth preserving. It’s a crisis hiding in plain sight.”
The above sounds familiar. Through money at it, instead of complying. Network adequacy is a foundational component. Waiving does not serve the system or Patients.
You can't enforce a network standard unless you can mandate providers join networks.
Why would 90% of plans "fall short of the standard"? Last I looked, most networks prefer to contract with every qualified provider - if only so that they can charge a profitable amount as a network fee.
And, it isn't limited to "insurance companies". Keep in mind a significant minority of Americans are enrolled in self-insured health plans.
So an "inadequate" provider network is just as likely the outcome from providers who do not want to contract at competitive prices. And, of course, with the No Surprises Act, we have started to see providers reject network participation in order to leverage the NSA's IDR process - where we have seen some unbelievable awards far in excess of the network allowable amount (the QPA). That is, the NSA is undermining the ability of networks to retain or to enroll providers.
So, apparently, you favor significant increases in costs to meet whatever a provider demands to join a network, or, do you believe Americans have a right to health care, and that federal, state and local governments should be able to set prices below cost (as they do for Medicaid and Medicare) in the private market? Or, perhaps you want to return to traditional indemnity health plans, where there is no network contracting?
You conclude: "... The question Texas courts will ultimately have to answer is whether health plans that accept Texans’ premiums — and in many cases, taxpayer dollars through Medicaid and ACA subsidies — have an obligation to actually provide the care they’re paid to deliver. ..."
Amazing how you ignore the fact that price fixing in Medicaid, such that providers are not willing to accept Medicaid enrollees, is a feature, not a bug.
Here is propaganda in the form of junk mail pre-sorted and standard US postage paid United healthcare.
AARP Medicare supplement from United healthcare. AARP Medicare supplement insurance plans, insured by United healthcare insurance company (United Healthcare)(United healthcare Insurance company of New York for New York residence)
Then they have the nerve to print “Help protect your finances with a Medicare supplement insurance plan.”
PS I haven’t even looked at the back of envelope nor what might be lurking inside.
You can't enforce a network standard unless you can mandate providers join networks.
Why would 90% of plans "fall short of the standard"? Last I looked, most networks prefer to contract with every qualified provider - if only so that they can charge a profitable amount as a network fee.
And, it isn't limited to "insurance companies". Keep in mind a significant minority of Americans are enrolled in self-insured health plans.
So an "inadequate" provider network is just as likely the outcome from providers who do not want to contract at competitive prices. And, of course, with the No Surprises Act, we have started to see providers reject network participation in order to leverage the NSA's IDR process - where we have seen some unbelievable awards far in excess of the network allowable amount (the QPA). That is, the NSA is undermining the ability of networks to retain or to enroll providers.
So, apparently, you favor significant increases in costs to meet whatever a provider demands to join a network, or, do you believe Americans have a right to health care, and that federal, state and local governments should be able to set prices below cost (as they do for Medicaid and Medicare) in the private market? Or, perhaps you want to return to traditional indemnity health plans, where there is no network contracting?
You conclude: "... The question Texas courts will ultimately have to answer is whether health plans that accept Texans’ premiums — and in many cases, taxpayer dollars through Medicaid and ACA subsidies — have an obligation to actually provide the care they’re paid to deliver. ..."
Amazing how you ignore the fact that price fixing in Medicaid, such that providers are not willing to accept Medicaid enrollees, is a feature, not a bug.
Medicare underpays for various expenses and the fact that folks accept that only confirms that they have the ability to charge others more to make up for the losses - averaging 200% - 250% - 350% higher for those who are in health coverage options where the government doesn't fix prices.
Federal and state government fixed prices also apply to Medicaid, where many providers minimize the portion of their patient population covered there. Medicaid reimbursements average only 75% of Medicare rates, according to KFF. See: https://www.kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/?
Unit prices charged by providers in the US are highly variable, and often do not reflect the actual underlying cost to provide healthcare services. Some critics assert that Medicare generally underpays providers, while others argue that Medicare overpays for certain services. Additionally, the prices Medicare pays for drugs may not be a suitable benchmark for other payers.
Medicare is a price setter (price fixer) and uses a variety of approaches to determine the prices it will pay, depending on whether it is paying a hospital, doctor, drug or device. Through its rate setting process, Medicare aims to cover the costs that “reasonably efficient providers would incur in furnishing high-quality care.”
Despite common beginnings, there are marked differences across provider types in how the final reimbursement levels compare to the determined cost to provide a service.
The American Hospital Association (AHA) has long claimed that Medicare payment rates reimburse below the cost of care for many services. The payment-to-cost ratio represents average payment relative to average cost, with costs including both patient-specific clinical costs and fixed costs such as equipment, buildings and administrators’ salaries. A 2019 AHA survey found that Medicare reimbursement was $53.9 billion lower than actual costs. (See: American Hospital Association, Underpayment by Medicare and Medicaid Fact Sheet – January 2019 (January 2019). https://www.aha.org/factsheet/2019-01-02-underpayment-medicare-and-medicaid-fact-sheet-january-2019 )
According to the AHA, private insurance payments average 144.8 percent of cost, while payments from Medicare average 86.8 percent of cost. The study also revealed that two-thirds of hospitals received payments from Medicare that were less than cost. (See: American Hospital Association, Trend Watch Chartbook 2018: Trends Affecting Hospitals and Health Systems, Washington, D.C. (2018). https://www.aha.org/system/files/2018-07/2018-aha-chartbook.pdf )
The industry’s claims are supported by Medicare’s own data showing that hospital aggregate (inpatient and outpatient) Medicare profit margins (the difference between total net revenue and total expenses divided by total net revenue) were -9.9 percent in 2017. As a result, MedPAC recommended raising inpatient and outpatient payment rates for 2020.(See: Medicare Payment Advisory Commission (March 2019) http://www.medpac.gov/docs/defaultsource/reports/mar19_medpac_entirereport_sec.pdf )
As far as I know, there hasn't been substantial change in the reimbursement approaches/methods used by Medicare and Medicaid.
stop overcomplicating things. standardizing fees for medical services makes sense. doctors just want to treat patients and have no interest in financial gamesmanship.
Up to providers and the federal and state governments to stop overcomplicating things by actions designed to buy votes using price fixing (including, most recently, Rx prices) for the 45+% of Americans whose health coverage is supplied by Medicare, Medicaid and the VA.
I've offered a solution which would restrict government price fixing to a universal, federal government stop loss / reinsurance program for the 10% or so Americans of all ages who incure more than $25,000 of expenses in a calendar year.
I doubt Congress will agree to stop buying votes - pattern has been in place since the 1980's, exacerbated by President Bush's vote buying with Medicare Part D, with additional expansions since then.
You bring up a valid point here, Jack with generally inadequate Medicare/Medicaid reimbursement rates. Many providers do not accept these patients for that very reason. However, it’s my understanding that private insurers and providers workout those reimbursement rates as multiples of CMS rates. Still, taking on this segment of patients in practice isn’t that lucrative.
Is it a feature or a bug when access to care (specialized care in particular!) is concentrated in urban areas and elders often live in remote areas.
Your statement below sums this up very succinctly. Patients are taking a back seat; again….
“The court’s decision to grant temporary relief to insurers may preserve the “status quo” — but that status quo is one in which more than nine out of ten health plans in Texas were already failing to meet the state’s network adequacy standards. For patients in rural communities especially, that isn’t a status quo worth preserving. It’s a crisis hiding in plain sight.”
The above sounds familiar. Through money at it, instead of complying. Network adequacy is a foundational component. Waiving does not serve the system or Patients.
You can't enforce a network standard unless you can mandate providers join networks.
Why would 90% of plans "fall short of the standard"? Last I looked, most networks prefer to contract with every qualified provider - if only so that they can charge a profitable amount as a network fee.
And, it isn't limited to "insurance companies". Keep in mind a significant minority of Americans are enrolled in self-insured health plans.
So an "inadequate" provider network is just as likely the outcome from providers who do not want to contract at competitive prices. And, of course, with the No Surprises Act, we have started to see providers reject network participation in order to leverage the NSA's IDR process - where we have seen some unbelievable awards far in excess of the network allowable amount (the QPA). That is, the NSA is undermining the ability of networks to retain or to enroll providers.
https://www.statnews.com/2026/03/18/no-surprises-act-loophole-profits-scott-laroque-mpowerhealth-alla-laroque-halomd/
So, apparently, you favor significant increases in costs to meet whatever a provider demands to join a network, or, do you believe Americans have a right to health care, and that federal, state and local governments should be able to set prices below cost (as they do for Medicaid and Medicare) in the private market? Or, perhaps you want to return to traditional indemnity health plans, where there is no network contracting?
You conclude: "... The question Texas courts will ultimately have to answer is whether health plans that accept Texans’ premiums — and in many cases, taxpayer dollars through Medicaid and ACA subsidies — have an obligation to actually provide the care they’re paid to deliver. ..."
Amazing how you ignore the fact that price fixing in Medicaid, such that providers are not willing to accept Medicaid enrollees, is a feature, not a bug.
Exactly people require care.
Here is propaganda in the form of junk mail pre-sorted and standard US postage paid United healthcare.
AARP Medicare supplement from United healthcare. AARP Medicare supplement insurance plans, insured by United healthcare insurance company (United Healthcare)(United healthcare Insurance company of New York for New York residence)
Then they have the nerve to print “Help protect your finances with a Medicare supplement insurance plan.”
PS I haven’t even looked at the back of envelope nor what might be lurking inside.
You can't enforce a network standard unless you can mandate providers join networks.
Why would 90% of plans "fall short of the standard"? Last I looked, most networks prefer to contract with every qualified provider - if only so that they can charge a profitable amount as a network fee.
And, it isn't limited to "insurance companies". Keep in mind a significant minority of Americans are enrolled in self-insured health plans.
So an "inadequate" provider network is just as likely the outcome from providers who do not want to contract at competitive prices. And, of course, with the No Surprises Act, we have started to see providers reject network participation in order to leverage the NSA's IDR process - where we have seen some unbelievable awards far in excess of the network allowable amount (the QPA). That is, the NSA is undermining the ability of networks to retain or to enroll providers.
https://www.statnews.com/2026/03/18/no-surprises-act-loophole-profits-scott-laroque-mpowerhealth-alla-laroque-halomd/
So, apparently, you favor significant increases in costs to meet whatever a provider demands to join a network, or, do you believe Americans have a right to health care, and that federal, state and local governments should be able to set prices below cost (as they do for Medicaid and Medicare) in the private market? Or, perhaps you want to return to traditional indemnity health plans, where there is no network contracting?
You conclude: "... The question Texas courts will ultimately have to answer is whether health plans that accept Texans’ premiums — and in many cases, taxpayer dollars through Medicaid and ACA subsidies — have an obligation to actually provide the care they’re paid to deliver. ..."
Amazing how you ignore the fact that price fixing in Medicaid, such that providers are not willing to accept Medicaid enrollees, is a feature, not a bug.
Medicare fees are not below cost. 98% of physicians accept Medicare FFS (only ~1.2% opt out)- https://www.kff.org/medicare/how-many-physicians-have-opted-out-of-the-medicare-program/
I know at least one physician that would prefer that every patient were enrolled in Medicare FFS- and I am sure there are many others.
Certain physicians, agree! Overall, not so much.
Medicare underpays for various expenses and the fact that folks accept that only confirms that they have the ability to charge others more to make up for the losses - averaging 200% - 250% - 350% higher for those who are in health coverage options where the government doesn't fix prices.
Federal and state government fixed prices also apply to Medicaid, where many providers minimize the portion of their patient population covered there. Medicaid reimbursements average only 75% of Medicare rates, according to KFF. See: https://www.kff.org/medicaid/state-indicator/medicaid-to-medicare-fee-index/?
Unit prices charged by providers in the US are highly variable, and often do not reflect the actual underlying cost to provide healthcare services. Some critics assert that Medicare generally underpays providers, while others argue that Medicare overpays for certain services. Additionally, the prices Medicare pays for drugs may not be a suitable benchmark for other payers.
Medicare is a price setter (price fixer) and uses a variety of approaches to determine the prices it will pay, depending on whether it is paying a hospital, doctor, drug or device. Through its rate setting process, Medicare aims to cover the costs that “reasonably efficient providers would incur in furnishing high-quality care.”
Despite common beginnings, there are marked differences across provider types in how the final reimbursement levels compare to the determined cost to provide a service.
The American Hospital Association (AHA) has long claimed that Medicare payment rates reimburse below the cost of care for many services. The payment-to-cost ratio represents average payment relative to average cost, with costs including both patient-specific clinical costs and fixed costs such as equipment, buildings and administrators’ salaries. A 2019 AHA survey found that Medicare reimbursement was $53.9 billion lower than actual costs. (See: American Hospital Association, Underpayment by Medicare and Medicaid Fact Sheet – January 2019 (January 2019). https://www.aha.org/factsheet/2019-01-02-underpayment-medicare-and-medicaid-fact-sheet-january-2019 )
According to the AHA, private insurance payments average 144.8 percent of cost, while payments from Medicare average 86.8 percent of cost. The study also revealed that two-thirds of hospitals received payments from Medicare that were less than cost. (See: American Hospital Association, Trend Watch Chartbook 2018: Trends Affecting Hospitals and Health Systems, Washington, D.C. (2018). https://www.aha.org/system/files/2018-07/2018-aha-chartbook.pdf )
The industry’s claims are supported by Medicare’s own data showing that hospital aggregate (inpatient and outpatient) Medicare profit margins (the difference between total net revenue and total expenses divided by total net revenue) were -9.9 percent in 2017. As a result, MedPAC recommended raising inpatient and outpatient payment rates for 2020.(See: Medicare Payment Advisory Commission (March 2019) http://www.medpac.gov/docs/defaultsource/reports/mar19_medpac_entirereport_sec.pdf )
As far as I know, there hasn't been substantial change in the reimbursement approaches/methods used by Medicare and Medicaid.
stop overcomplicating things. standardizing fees for medical services makes sense. doctors just want to treat patients and have no interest in financial gamesmanship.
Up to providers and the federal and state governments to stop overcomplicating things by actions designed to buy votes using price fixing (including, most recently, Rx prices) for the 45+% of Americans whose health coverage is supplied by Medicare, Medicaid and the VA.
I've offered a solution which would restrict government price fixing to a universal, federal government stop loss / reinsurance program for the 10% or so Americans of all ages who incure more than $25,000 of expenses in a calendar year.
I doubt Congress will agree to stop buying votes - pattern has been in place since the 1980's, exacerbated by President Bush's vote buying with Medicare Part D, with additional expansions since then.
You bring up a valid point here, Jack with generally inadequate Medicare/Medicaid reimbursement rates. Many providers do not accept these patients for that very reason. However, it’s my understanding that private insurers and providers workout those reimbursement rates as multiples of CMS rates. Still, taking on this segment of patients in practice isn’t that lucrative.