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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.
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.
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.
Secretary of the Navy John Phelan speaks, as President Trump listens, at Trump’s Mar-a-Lago club on Dec. 22 in Palm Beach, Fla.
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WASHINGTON — Navy Secretary John Phelan is leaving his job, the Pentagon abruptly announced Wednesday, the first head of a military service to depart during President Trump’s second term but just the latest top defense leader to step down or be ousted.
No reason was given for the unexpected departure of the Navy’s top civilian official, coming as the sea service has imposed a blockade of Iranian ports and is targeting ships linked to Tehran around the world during a tenuous ceasefire in the war. Another Trump loyalist is taking over as acting head of the Navy: Undersecretary Hung Cao, a 25-year Navy combat veteran who ran unsuccessful campaigns for the U.S. Senate and House in Virginia.
Phelan’s departure is the latest in a series of shakeups of top leadership at the Pentagon, coming just weeks after Defense Secretary Pete Hegseth fired the Army’s top uniformed officer, Gen. Randy George. Hegseth also has fired several other top generals, admirals and defense leaders since taking office last year.
The firings began in February 2025, when Hegseth removed military leaders, including Adm. Lisa Franchetti, the Navy’s top uniformed officer, and Gen. Jim Slife, the No. 2 leader at the Air Force. Trump also fired Gen. Charles “CQ” Brown Jr. as chairman of the Joint Chiefs of Staff.
Showing how sudden the latest move was, Phelan had addressed a large crowd of sailors and industry professionals on Tuesday at the Navy’s annual conference in Washington and spoke with reporters about his agenda. He also hosted the leaders of the House Armed Services Committee to discuss the Navy’s budget request and efforts to build more ships, according to a social media post from his office.
Pentagon spokesman Sean Parnell said in a post on X that Phelan was “departing the administration, effective immediately.”
Phelan had been a major Trump donor
Phelan had not served in the military or had a civilian leadership role in the service before Trump nominated him for secretary in late 2024. He was seen as an outsider being brought in to shake up the Navy.
Hung Cao speaks during the Republican National Convention on July 16, 2024, in Milwaukee.
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Phelan was a major donor to Trump’s campaign and had founded the private investment firm Rugger Management LLC. According to his biography, Phelan’s primary exposure to the military came from an advisory position he held on the Spirit of America, a nonprofit that supported the defense of Ukraine and the defense of Taiwan.
The Associated Press could not immediately reach Phelan’s office for comment. The White House did not answer questions and instead responded by sending a link to Parnell’s statement.
Phelan is leaving during a busy time for the Navy. It has three aircraft carriers deployed in or heading to the Middle East, while the Trump administration says all the armed forces are poised to resume combat operations against Iran should the ceasefire expire.
The Navy also has maintained a heavy presence in the Caribbean, where it has been part of a campaign of strikes against alleged drug boats. It also played a major role in the capture of Venezuelan leader Nicolás Maduro in January.
New acting Navy secretary ran unsuccessful bids for Congress
Taking over as acting secretary is Cao, who ran a failed U.S. Senate bid in Virginia to try to unseat Democratic Sen. Tim Kaine in 2024. He had Trump’s endorsement in the crowded Republican primary and gave a speech at the 2024 Republican National Convention.
Cao’s biography includes fleeing Vietnam with his family as a child in the 1970s. In a campaign video for his Senate bid, he compared Vietnam’s communist regime during the Cold War to the administration of Democratic President Joe Biden.
During his one debate with Kaine, Cao criticized COVID-19 vaccine mandates for service members as well as the military’s diversity, equity and inclusion efforts.
“When you’re using a drag queen to recruit for the Navy, that’s not the people we want,” Cao said from the debate stage. “What we need is alpha males and alpha females who are going to rip out their own guts, eat them and ask for seconds. Those are the young men and women that are going to win wars.”
Trump and Hegseth have railed against DEI in the military, banning the efforts and firing people accused of supporting such programs.
When he ran for Congress in Virginia in 2022, Cao expressed opposition to aid for Ukraine during a debate against his Democratic opponent.
“My heart goes out to the Ukrainian people. … But right now we’re borrowing $55 billion from China to pay for the war in Ukraine. Not only that, we’re depleting our national strategic reserves,” Cao said.
Cao graduated from the prestigious Thomas Jefferson High School for Science and Technology in Alexandria, Virginia, before attending the U.S. Naval Academy.
He was commissioned as a special operations officer and went on to serve with SEAL teams and special forces in Iraq, Afghanistan and Somalia before retiring at the rank of captain, according to his Senate campaign biography.
Cao also earned a master’s degree in physics and had fellowships at the Massachusetts Institute of Technology and Harvard University.
Since becoming Navy undersecretary, Cao has championed returning to duty service members that refused a Biden-era mandate to take the COVID-19 vaccine.
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