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Vulnerable Americans are stuck in a Medicare-Medicaid maze. Is a fix in sight?
People who qualify for both Medicare and Medicaid face maddening challenges accessing health care. The government spends $500 billion on this care, yet patients often can’t get what they need.
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People who qualify for both Medicare and Medicaid face maddening challenges accessing health care. The government spends $500 billion on this care, yet patients often can’t get what they need.
amtitus/Getty Images
On Thursday, a bipartisan group of six U.S. Senators will unveil a bill aimed at helping millions of Americans trapped in a special kind of health insurance hell. These people, who are among the country’s sickest and poorest patients, are covered by two government health insurance programs — Medicare and Medicaid — yet still struggle to get the care they need.
Their struggles persist despite Medicare and Medicaid combining to spend nearly half a trillion dollars a year — almost $40,000 per person on average — on these patients, who are sometimes called “duals” or “the dually eligible.”
“If you can come up with a set of solutions that can save the taxpayer money and make a patient’s life better, by golly you’ve found a sweet spot,” the bill’s lead author, Sen. Bill Cassidy, R-Louisiana, said in an interview with Tradeoffs.
The bill, known as the DUALS Act of 2024, targets what many experts see as the fundamental source of this system’s inefficiency and ineffectiveness: its fragmentation. It will be introduced later today at a press conference by Democratic Senators Tom Carper, Mark Warner and Bob Menendez and Republicans Bill Cassidy and John Cornyn. Sen. Tim Scott, Republican of South Carolina, is also a co-sponsor of the bill.
Right now, to access vital services, most of the 12 million ‘duals’ are forced to deal with two different insurance plans and decipher two sets of confusing, sometimes conflicting rules. Medicare covers more urgent medical needs like surgeries while Medicaid pays for longer-term services like regular home visits from an aide. This bill aims to remove the patient from the middle of that maze.
The legislation mandates states to offer people at least one single, seamless insurance plan option that manages all of their medical, behavioral and long-term care — combining the Medicaid and Medicare sides of their benefits. Lawmakers hope the move makes care better and more cost-effective.
Senators promise relief to patients stuck in the middle of a $500 billion mess
People qualify as “dually eligible” because of their low incomes and by either having a long-term disability, being over 65 or all three. Any delay to receiving care can take a toll. Bronx resident Saleema Render-Hornsby experienced that firsthand in 2022.
The 34-year-old has spina bifida — a spinal cord issue that limits her use of her lower legs — and her trusty wheelchair nicknamed “the Cadillac” broke down in the middle of a New York City street. Medicare and Medicaid tossed her request for a new chair around like a hot potato.
“I shouldn’t be stuck in the middle,” Render-Hornsby said. “Why do I have to keep repeating what I need until I’m blue in the face?”
After multiple appeals and her mother buying a temporary chair that caused Render-Hornsby back aches, nerve pain and pressure sores, Render-Hornsby got her chair.
It took 20 months.
Bill’s impact in doubt
Today, just north of 1 million duals are enrolled in a plan that’s as seamless as the kind outlined in this legislation. The bill requires states to pick a plan from a list of options that would be approved by the federal government.
Industry groups, consumer advocates and academic experts applaud the bill’s authors for lighting a federal fire under states to solve this annual half-a-trillion-dollar problem. However, many question if it would achieve the bill sponsors’ twin goals of saving taxpayer money and improving patient health.
The legislation is silent on many key technical details like how much health insurance plans would be paid to run these new seamless plans or how plan quality would be measured, they point out.
“We have the opportunity to be transformational and to hold health plans accountable,” said Amber Christ, managing director of health advocacy for the nonprofit Justice in Aging. “I don’t see this legislation really moving the needle.”
One major barrier to the bill’s success is that states lack a proven formula to build a super seamless plan. Twelve states have participated in a pilot program created by the Affordable Care Act to test different approaches, but the results over the last decade have been disappointing.
“There are some exceptions, but we have not seen consistent success across states in terms of lowering health care spending or improving outcomes,” said Alice Burns, associate director at the health research organization KFF.
A murky marketplace makes better plans hard to find
Perhaps the sharpest critiques are aimed at the bill’s failure to clean up the insurance marketplace for duals.
“This legislation adds one more thing to an already confusing landscape,” said Allison Rizer, executive vice president at ATI Advisory, a research and consulting firm. “It does not do away with any existing programs.”
Some dually eligible people today have as many as 100 local plans to choose from, according to Rizer, who says the thicket of options needs thinning out.
Private insurance companies have flocked to this market over the last decade, lured by higher payment rates and other regulatory changes. The industry now offers nearly 900 different insurance plans nationwide designed specifically for the dually eligible.
That’s on top of thousands of standard plans available to all Medicare beneficiaries. Almost all of these plans provide little help coordinating people’s Medicare and Medicaid benefits.
“This is what’s broken with health care,” said Hong Truong who helped her mother enroll in a private Medicare plan designed specifically for dually eligible people. Her mom, who lives in San Jose, Calif., suffers from severe kidney disease.
She still had to deal with two different insurers and neither offered help when Truong needed to find her mom an in-home caregiver who spoke Chinese or Vietnamese — languages that Truong does not speak. She relied instead on relatives to act as recruiters.
The poorly coordinated coverage also left Truong to her own devices when her mom’s transportation service repeatedly failed to pick her up from her dialysis appointments. Truong ended up orchestrating drivers via the ride-sharing app Lyft and paying out of her own pocket.
“Everyone just referred me to somebody else,” Truong said. “It was all so frustrating.”
Aggressive marketing by insurers and brokers only further muddies this marketplace. A survey by the Commonwealth Fund found that, compared to wealthier Medicare beneficiaries, those with low incomes were nearly twice as likely to report being misled by advertisements and feeling pressured by a broker to switch plans.
Rather than clearing out some of the clutter, this legislation instead proposes shepherding people into these new, more seamless plans by automatically enrolling them (with a chance to opt out.) That tactic has done poorly in some states. Instead, their seamless plans have seen low enrollment, and some patients have experienced disruptions in their care.
Cassidy’s bill faces an uphill climb
Sen. Cassidy acknowledges that his bill faces slim odds of passing this session. But he believes this population’s half-a-trillion dollar price tag and the country’s rapidly aging demographics make this problem too big to ignore for much longer.
At a minimum, he believes this bill will help Congress “get comfortable” with this wonky issue and predicts they’ll ultimately feel compelled to act. One sign of progress: Senate aides said they expect a hearing on the topic to happen later this year.
If momentum eventually builds then Rizer says lawmakers will face a difficult question about how to make the most of a rare opportunity to help an overlooked population and rein in federal spending.
“Do you go big?” Rizer asked, “Or do you settle for something that’s going to kick the can another 10 to 15 years down the road?”
Absent major changes to the bill introduced today, Rizer said, the latter is far more likely.
This story comes from the health policy podcast Tradeoffs. Dan Gorenstein is Tradeoffs’ executive editor, and Leslie Walker is a senior reporter/producer for the show, where a version of this story first appeared. Tradeoffs’ weekly newsletter brings more health policy reporting to your inbox.
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Senate Adopts GOP Budget, Laying the Groundwork to Fund ICE and Reopen DHS
The Senate early Thursday morning adopted a Republican budget blueprint that would pave the way for a $70 billion increase for immigration enforcement and the eventual reopening of the Department of Homeland Security.
Republicans pushed through the plan on a nearly party-line vote of 50 to 48. It came after an overnight marathon of rapid-fire votes, known as a vote-a-rama, in which the G.O.P. beat back a series of Democratic proposals aimed at addressing the high cost of health care, housing, food and energy. The debate put the two parties’ dueling messages on vivid display six months before the midterm elections.
Republicans, who are using the budget plan to lay the groundwork to eventually push through a filibuster-proof bill providing a multiyear funding stream for President Trump’s immigration crackdown, used the all-night session to highlight their hard-line stance on border security, seeking to portray Democrats as unwilling to safeguard the country.
Democrats tried and failed to add a series of changes aimed at addressing cost-of-living issues, seizing the opportunity to hammer Republicans as out of touch with and unwilling to act on the concerns of everyday Americans.
Here’s what to know about the budget plan and the nocturnal ritual senators engaged in before adopting it.
Republicans are seeking a way around a filibuster on D.H.S. funding.
The budget blueprint is a crucial piece of Republicans’ plan to fund the Department of Homeland Security and end a shutdown that has lasted for more than two months. After Democrats refused to fund immigration enforcement without new restrictions on agents’ tactics and conduct, the G.O.P. struck a deal with them to pass a spending bill that would fund everything but ICE and the Border Patrol. Republicans said they would fund those agencies through a special budget bill that Democrats could not block.
“We can fix this with Republican votes, and we will,” said Senator Lindsey Graham, Republican of South Carolina and the Budget Committee chairman. “Every Democrat has opposed money for the Border Patrol and ICE at a time of great peril.”
In resorting to a new budget blueprint, Republicans laid the groundwork to deny Democrats a chance to stop the immigration enforcement funding. But they also submitted themselves to a vote-a-rama, in which any senator can propose unlimited changes to such a measure before it is adopted.
The budget measure now goes to the House, which must adopt it before lawmakers in both chambers can draft the legislation funding immigration enforcement. That bill will provide yet another opportunity for a vote-a-rama even closer to the November election.
Democrats used the moment to hammer Republicans on affordability.
Democrats took to the floor to criticize Republicans for supercharging funding for federal immigration enforcement rather than moving legislation that would address Americans’ concerns over affordability.
“This is what Republicans are fighting for,” said Senator Chuck Schumer, Democrat of New York and the Democratic leader. “To maintain two unchecked rogue agencies that are dreaded in all corners of this country instead of reducing your health care costs, your housing costs, your grocery costs, your gas costs.”
Democrats offered a host of amendments along those lines, all of which were defeated by Republicans — and that was the point. The proposals were meant to put the G.O.P. in a tough political spot, showcasing their opposition to helping Americans afford high living costs. Fewer than a handful of G.O.P. senators crossed party lines to support them.
Republicans blocked Democrats’ proposals to address high living costs.
The G.O.P. thwarted an effort by Mr. Schumer to require that the budget measure lower out-of-pocket health care costs for Americans. Two Republicans who are up for re-election this year, Senators Susan Collins of Maine and Dan Sullivan of Alaska, voted with Democrats, but the proposal was still defeated.
Republicans also squelched a move by Senator Ben Ray Lujan, Democrat of New Mexico, to create a fund that would lower grocery costs and reverse cuts to food aid programs that Republicans enacted last year. Ms. Collins and Mr. Sullivan again joined Democrats.
Also defeated by the G.O.P.: a proposal by Senator John Hickenlooper, Democrat of Colorado, to address rising consumer prices brought on by Mr. Trump’s tariffs and the war in Iran; one by Senator Edward J. Markey, Democrat of Massachusetts, to require the budget measure to address rising electricity prices, and another by Mr. Markey to create a fund to bring down housing costs.
Senator Jon Ossoff, a Democrat who is up for re-election in Georgia, also sought to add language requiring the budget plan to address health insurance companies denying or delaying access to care, but that, too was blocked by Republicans.
Republicans sought to amplify their hard-line messages on immigration, voter I.D. and transgender care.
While Republicans had fewer proposals for changes to their own budget plan, they also sought to offer measures that would underscore their aggressive stance on immigration enforcement and dare Democrats to vote against them.
Mr. Graham offered an amendment to allocate funds toward a deficit-neutral reserve fund relating to the apprehension and deportation of adult immigrants convicted of rape, murder, or sexual abuse of a minor after illegally entering the United States. It passed unanimously.
Senator Josh Hawley, Republican of Missouri, sought to bar Medicaid payments to Planned Parenthood, which provides abortion and other services, and criticized the organization for providing transgender care to minors. Senator John Kennedy, Republican of Louisiana, also attempted to tack on the G.O.P. voter identification bill, known as the SAVE America Act. Both proposals were blocked when Democrats, joined by a few Republicans, voted to strike them as unrelated to the budget plan.
The Republicans who crossed party lines to oppose their own party’s proposals for new voting requirements were Ms. Collins along with Senators Mitch McConnell of Kentucky, Lisa Murkowski of Alaska and Thom Tillis of North Carolina.
Ms. Collins and Ms. Murkowski also opposed the effort to block payments to Planned Parenthood.
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Who is John Phelan, the US Navy Secretary fired by Pete Hegseth?
The firing of US Navy Secretary John Phelan is the latest in a shakeup of the American military during the war on Iran, now in its eighth week.
The Pentagon said Phelan would leave office immediately.
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“On behalf of the Secretary of War and Deputy Secretary of War, we are grateful to Secretary Phelan for his service to the Department and the United States Navy,” said chief Pentagon spokesperson Sean Parnell. “We wish him well in his future endeavours”.
His firing comes at a critical moment, with US naval forces enforcing a blockade on Iranian ports and ships, and maintaining a heavy presence around the Strait of Hormuz, through which 20 percent of the world’s oil and gas passes during peacetime.
Although the Pentagon gave no official reason for the dismissal, reports indicate the decision was linked to internal disputes, including tensions with Defense Secretary Pete Hegseth.
Phelan’s removal is part of a broader pattern of dismissals and restructuring within the US military under President Donald Trump’s administration – including during the current war.
So, who is John Phelan, and what impact could his firing have on US military strategy?
Who is John Phelan?
As the US Navy’s top civilian official, Phelan had various responsibilities, including overseeing recruiting, mobilising and organising, as well as construction and repair of ships and military equipment.
He was appointed in 2024 as a political ally of Trump, despite having no prior military or defence leadership experience.
Before entering government, Phelan was a businessman and investment executive, as well as a major Republican donor and fundraiser — a background that is fairly common among Trump appointees and advisers. The US president’s two top diplomatic negotiators, for instance, are Steve Witkoff — a real estate businessman with no prior diplomatic experience – and Trump’s son-in-law, Jared Kushner.
According to the Reuters news agency, Phelan’s tenure quickly became controversial. He faced criticism for moving too slowly on shipbuilding reforms and for strained relationships with key Pentagon figures, including Hegseth and his deputy, Steve Feinberg.
In addition, Phelan was reportedly under an ethics investigation, which may have weakened his standing in the administration.
Navy Undersecretary Hung Cao, who was also reported to have a difficult relationship with Phelan, has become acting secretary. Fifty-four-year-old Cao is a 25-year Navy veteran who previously ran as a Republican candidate for the US Senate and House of Representatives in 2022 and 2024 respectively, but was unsuccessful on both occasions.
Democrats have criticised Phelan’s removal, calling it “troubling”.
“I am concerned it is yet another example of the instability and dysfunction that have come to define the Department of Defense under President Trump and Secretary Hegseth,” said Senator Jack Reed, the top Democrat on the Senate Armed Services Committee.
Who else has the Trump administration fired since the war with Iran began?
Phelan’s removal is the latest in a series of senior military leaders being fired or are leaving during the US-Israeli war on Iran, in addition to others since Trump was re-elected.
Among the most notable dismissals was Army Chief of Staff General Randy A. George, in the first week of April. George was appointed in 2023 under former US President Joe Biden.
According to reports, Hegseth also fired the head of the Army’s Transformation and Training Command, a unit concerned with modernising the army, and the Army’s chief of chaplains. The Pentagon has not confirmed their dismissal.
Why is Phelan’s dismissal significant?
The 62-year-old’s removal comes during a fragile ceasefire with Iran, as the US continues to move more naval assets into the region.
The Navy is central to enforcing Trump’s blockade of Iranian ports to restrict Iran’s oil exports and apply economic pressure on Tehran, as the US president looks eager to wrap up the war, which is deeply unpopular to many Americans.
However, there are no indications that Trump is willing to end the blockade or other naval operations in the Strait of Hormuz, as negotiations between Washington and Tehran have come to a standstill.
Tensions have escalated in recent days after the US military seized an Iranian container ship. The US claimed it was attempting to sail from the Arabian Sea through the Strait of Hormuz to the Iranian port of Bandar Abbas.
Tehran responded by describing the attack and hijack as an act of “piracy”.
Iran has since captured two cargo ships and fired at another.
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Not a Deal-Breaker: White House Downplays Iranian Action Near the Strait
Just two weeks ago, President Trump threatened to wipe out Iran’s civilization if it did not open the Strait of Hormuz. Days later, he said any Iranian “who fires at us, or at peaceful vessels, will be BLOWN TO HELL!”
Yet on Wednesday, after Iran seized two ships near the Strait of Hormuz, the White House was quick to argue the action was not a deal breaker for potential peace negotiations.
“These were not U.S. ships,” Karoline Leavitt, the White House press secretary, said on Fox News. “These were not Israeli ships.” Therefore, she explained, the Iranians had not violated a cease-fire with the United States that Mr. Trump has extended indefinitely.
She cautioned the news media against “blowing this out of proportion.”
The surprisingly tolerant tone from the White House suggests Mr. Trump is not eager to reignite a war that he started alongside Israel on Feb. 28 — a war that has proved unpopular with Americans and has gone on longer than he initially estimated.
The president on Tuesday extended a cease-fire between the United States and Iran that had been set to expire within hours, saying he wanted to give Tehran a chance to come up with a new proposal to end the war.
The American military has displayed its overwhelming might during the war, successfully striking thousands of targets. But it remains unclear whether Mr. Trump will accomplish the political objectives of the war.
The Iranian regime, even after its top leaders were killed, is still intact. Iran has not agreed to Mr. Trump’s demands to turn over its nuclear capabilities to the United States or significantly curtail them. And the Strait of Hormuz, a key passageway for world commerce that was open before the war, remains closed.
Nevertheless, the White House has repeatedly highlighted the military successes on the battlefield as evidence it is winning the war.
“We have completely confused and obliterated their regime,” Ms. Leavitt said on Fox Wednesday. “They are in a very weak position thanks to the actions taken by President Trump and our great United States armed forces, and so we will continue this important mission on our own.”
The oscillation between threats and a more conciliatory tone has long been one of Mr. Trump’s signature negotiating strategies.
Potential peace talks between the two countries are on hold. Vice President JD Vance had been poised to fly to Islamabad for negotiations. But the trip was postponed until Iran can “come up with a unified proposal,” Mr. Trump said.
The United States recently transmitted a written proposal to the Iranians intended to establish base-line points of agreement that could frame more detailed negotiations. The document covers a broad range of issues, but the core sticking points are the same ones that have bedeviled Western negotiators for more than a decade: the scope of Iran’s uranium enrichment program and the fate of its stockpile of enriched uranium.
Mr. Trump has not spoken publicly about the cease-fire, other than on social media. On Wednesday, he also posted about topics including “my Apprentice Juggernaut” — a reference to his former television show; the Virginia elections, which he called “rigged”; and a new book about Supreme Court Justice Samuel A. Alito Jr.
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