Podcast Summary: Becker’s Healthcare Podcast

Episode: Jakob Emerson on Medicare Advantage Changes, GLP-1 Access and Shifts in the Payer Landscape
Date: December 4, 2025
Host: Scott Becker
Guest: Jakob Emerson, Writer, Journalist, Editor

Overview

In this timely episode, host Scott Becker and healthcare journalist Jakob Emerson delve into the latest regulatory changes proposed for Medicare Advantage (MA), the evolving landscape of GLP-1 drug access, and persistent shifts in the broader payer market. Emerson offers insight into policy adjustments, systemic challenges, and emerging trends impacting patients, providers, and insurers, drawing from recent CMS documents and industry reporting.

Key Discussion Points & Insights

1. Medicare Advantage 2027 Proposed Rule

• Major changes by CMS:
  Emerson details how CMS has published the 2027 Medicare Advantage and Part D proposed rule—a comprehensive document governing MA plans’ operations and funding.

  • Quote: “CMS is proposing that for those who have providers that leave their plan’s network midyear, there can just be a modified special enrollment period so that those members can find covered care within their area.” (03:36, Jakob Emerson)
  • This proposed modification would ease the process for seniors whose provider networks change mid-year, allowing them to switch plans without the current, lengthy administrative hurdles.

• Backdrop:

  • Growing dissatisfaction among health systems with MA plans’ administrative burdens, prior authorization denial rates, and reimbursement delays.
  • Some hospital systems are dropping problematic MA carriers—or even all MA contracts.
  • The new rule would streamline member transitions when network disruptions occur.

Notable Exchange

• Scott Becker observes: “You’ve got both health systems increasingly disliking the Medicare Advantage plans…and then you’ve got Medicare patients all over the board in terms of their satisfaction with Medicare Advantage. Some very positive, some negative, a real mix. But fascinating to see these kinds of changes.” (03:43, Scott Becker)

2. Risk Adjustment and Coding Feedback

• CMS seeks input:

  • The agency is soliciting feedback on its risk adjustment system. Stakeholders are urged to comment on whether coding practices and existing rules disadvantage smaller, newer, or nonprofit MA plans compared to large national players.
  • Problems highlighted include incentivizing “upcoding” (reporting higher-severity diagnoses for greater payments), which has led to headlines about fraud.

• Market reality:

  • Smaller MA plans struggle to keep pace amid complex regulation and payment incentives that favor larger incumbents like United, Humana, and CVS Aetna.
  • Quote: “CMS is saying that we understand that regional, smaller, nonprofit Medicare Advantage plans are struggling compared to the big guys right now.” (05:40, Jakob Emerson)

3. GLP-1 Access Amid Rising Costs

• Access disparity:

  • Emerson discusses new data revealing declining GLP-1 coverage for obesity treatment across ACA/Obamacare plans.
  • Only California and North Dakota mandate all marketplace plans cover GLP-1s for obesity; in most states, access is sparse and inconsistent.
  • Quote: “GLP-1 access, if you’re on an Obamacare or ACA plan going into next year, it’s declining…It comes down to luck that you live in a state that might offer this kind of thing.” (07:16, Jakob Emerson)

• Market distortion:

  • The price for GLP-1s varies wildly: out-of-pocket or compound pharmacy options may cost less than insurance-covered ones due to market and PBM (pharmacy benefit manager) practices.
  • This exposes a paradox—sometimes using insurance can cost more than paying directly.
  • Quote: “Sometimes when you use your health insurance to cover a prescription medication it actually makes it more expensive than if you just paid out of pocket or…went to the manufacturer directly.” (08:55, Jakob Emerson)
  • Scott Becker likens the price confusion to “going to college. Nobody pays the same price anymore.” (08:23, Scott Becker)

4. ACA Subsidies and Industry Concerns

• Uncertain future:
  • Emerson flags ongoing concern among hospitals and insurers about the fate of ACA subsidies, with negotiations stalling at the federal level.
  • Executives worry about the business impact if these subsidies lapse.
  • Quote: “That’s really the main issue we’re going to be tracking pretty much day by day at this point through the end of the year…because the hospital and insurance executives that we’re talking to daily are worried in terms of what it means for their businesses if these subsidies don’t continue.” (10:44, Jakob Emerson)

Memorable Quotes & Timestamps

• On streamlined plan switching (Medicare Advantage):
  “CMS wants to remove all these roadblocks that currently exist when this situation happens and make it much easier for these seniors that are now, you know, surprise, out of network with their local hospital system.” (03:36, Jakob Emerson)

• On market inequity:
  “CMS is saying that we understand that regional, smaller, nonprofit Medicare Advantage plans are struggling compared to the big guys right now.” (05:40, Jakob Emerson)

• On GLP-1 insurance paradox:
  “Sometimes when you use your health insurance to cover a prescription medication it actually makes it more expensive than if you just paid out of pocket.” (08:55, Jakob Emerson)

• On price absurdity:
  “It’s like going to college. Nobody pays the same price anymore. GLP-1s seem to be the same thing…just insane how that’s evolved.” (08:23, Scott Becker)

Key Segment Timestamps

• 01:31 – 03:36: Medicare Advantage 2027 special enrollment reform
• 04:14 – 06:15: CMS feedback on risk adjustment and market disadvantages for small MA plans
• 06:31 – 08:55: GLP-1 coverage landscape on ACA exchanges; pricing confusion
• 10:26 – 10:59: ACA subsidies outlook and industry anxiety

Tone & Language

Throughout the episode, the discussion is insightful yet accessible, mixing policy detail with everyday analogies. Becker voices incredulity at the market paradoxes, while Emerson provides careful, nuanced analysis, often flagging the complexities and fast-moving nature of these healthcare issues.

Conclusion

This episode offers a clear, concise snapshot of the transformative currents sweeping through Medicare Advantage, drug coverage, and the payer world at large. Jakob Emerson’s reporting distills voluminous policy shifts and market data into actionable insights for hospital executives, insurers, and policy watchers, shedding light on both opportunities and challenges as 2026 approaches.