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Hospitals Called Out for Unnecessary Back Surgeries on Seniors

Analysis turned up 200,000 unneeded procedures costing Medicare $2 billion over 3 years

by Cheryl Clark, MedPage Today

October 8, 2025

The Lown Institute called out dozens of hospitals for performing unnecessary surgeries on Medicare beneficiaries with low back pain, putting patients at risk of serious complications with no evidence of clinical benefit.

Its analysis focused on high-volume hospitals that performed at least 500 spinal fusion/laminectomy or vertebroplasty procedures over a 3-year period — finding more than 200,000 unnecessary procedures amounting to about $1.9 billion in wasted Medicare spending during that time.

“We’re not doing this just to draw attention to the fact that there is unnecessary surgery,” Lown president Vikas Saini, MD, told MedPage Today. “We’re doing it to track how much, so people who want to do something about it have a guideline.”

As for the doctors who are performing these unnecessary procedures, Saini said there are “true believer” surgeons who insist that the procedure can benefit their patients despite a lack of evidence, “and there are those who are more skeptical. … But let’s be magnanimous and say that all of this comes from a place of wanting to help, and hope that it will help.”

“But if we’re really going to have a reliable, effective, and affordable healthcare system, we can’t just base it all on a hope and a prayer,” he said. “It has to be based on evidence. Hope is easy to have, but in the end, it doesn’t solve the problem.”

The report also noted the high rate of complications from these procedures. Some 18% of spinal fusion procedures result in infection, blood clots, stroke, pneumonia, heart and lung problems, and in some cases, death.

The Lown Institute’s list was taken from Medicare data. The hospitals with the highest rates of spinal fusion/laminectomy overuse are Mount Nittany Medical Center in Pennsylvania (57.2% of 505 procedures), Concord Hospital in New Hampshire (39.5% of 517 procedures), and Lutheran Hospital of Indiana (38.6% of 1,232 procedures).

The hospitals with the highest rates of vertebroplasty overuse included Kettering Health Miamisburg in Ohio (56.1% of 578 procedures), Shannon Medical Center in Texas (54.6% of 694 procedures), and St. Elizabeth Florence Hospital in Kentucky (50.1% of 668 procedures).

The report also applauded hospitals with the lowest rates of these procedures. Avala Hospital in Louisiana, Northwest Specialty Hospital in Idaho, and Baylor Surgical Hospital at Las Colinas in Texas all had spinal fusion/laminectomy overuse rates of 1.2% or lower. Metrohealth Medical Center in Ohio, Harborview Medical Center in Washington, and the Mayo Clinic Health System-La Crosse were among 11 hospitals with no vertebroplasty overuse.

The report also highlighted enormous state variation in rates of overuse of these procedures. California, Florida, Texas, and Pennsylvania had the highest amount of overuse of spinal fusion procedures, with at least 5,000 unnecessary procedures in each state. Texas, Florida, and Ohio had the highest volume of vertebroplasty overuse with at least 6,000 unnecessary procedures in each of those states.

Spinal fusion/laminectomy procedures were considered overused when performed for low back pain, but excluded patients with radicular symptoms, trauma, herniated disc, discitis, spondylosis, myelopathy, radiculopathy, radicular pain, or scoliosis.

Spinal fusion-only procedures were not considered overused when performed for stenosis with neural claudication and spondylolisthesis. Laminectomy-only interventions were not considered overused when performed in patients with stenosis who had neural claudication.

Vertebroplasty procedures were considered overused when performed in patients with spinal fractures caused by osteoporosis, but the list excluded patients with bone cancer, myeloma, or hemangioma.

The Medicare data included fee-for-service patients’ procedures from 2021 to 2023 and Medicare Advantage patients’ procedures from 2020 to 2022. Procedures performed on Medicare beneficiaries under age 65 were not included.

Saini said the report concentrated just on those hospitals that performed at least 500 of these procedures. For the spinal fusion/laminectomy analysis, 466 hospitals were evaluated, and for vertebroplasty, 625 hospitals were included.  He said these procedures are extremely expensive, costing $14,500 for spinal fusion and $4,200 for vertebroplasty.

Asked what efforts he thinks will reduce the number of these unnecessary back pain procedures, Saini suggested federal oversight, such as the WISeR (Wasteful and Inappropriate Service Reduction) model, could have a larger role, perhaps with more targeted prior authorization requirements or guidelines.

“There’s no way we can replace clinical judgment of the physician in the exam room,” Saini said. “We can’t have the federal government practicing medicine.”

But a lot of clinicians “just aren’t with the program and some of them will argue with you until they’re blue in the face that the data just doesn’t refute the way they practice,” he said, noting the saying, “It’s hard to get somebody to understand something when their salary depends on them not understanding.”

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Number Of Family Caregivers Has Skyrocketed in The USA

By Dennis Thompson, HealthDay News – Jul 25, 2025

The number of Americans caring for an older or disabled family member has risen dramatically during the past 10 years, according to a new AARP policy report. There’s been a 45% increase in the number of family caregivers between 2015 and 2025, with 63 million Americans now looking after an aging or ailing relative, Rita Choula, senior director of caregiving at the AARP Public Policy Institute, told HealthDay Now in an interview. Overall, 1 in 4 Americans (24%) is now a family caregiver, according to the Caregiving in the U.S. 2025 report from the AARP and the National Alliance on Caregiving.

“That is a huge number when you think about the individuals that are providing this care,” Choula said. “We also know that family caregivers are doing higher intensity care, so they’re doing more complex tasks in addition to things such as providing transportation or taking individuals to appointments. And they’re doing it for longer periods of time.”

The aging of the U.S. Baby Boomers is driving this increase, she said. Nearly half of the care recipients are 75 or older, and many face multiple chronic health conditions, the report says. “People are living longer and with that, they’re getting sicker and they’re living with illnesses that decades ago they might not have lived that long for,” Choula said. “And so now we see individuals that are still in the home with very serious illnesses that need individuals to provide that care.”

There’s also been a reassessment in terms of the importance of caregiving from family members, she added. “Even up until 2020, when we talked about somebody being a family caregiver and really recognizing the different things that they did, they didn’t necessarily associate that with a caregiving role,” Choula said. “They were being the daughter, they were being the spouse, they were doing the things that they were called to do.” About 70% of caregivers, 18 to 64 juggle a full or part-time job with their care responsibilities, the report found.

“Imagine being that family member who is working a full-time 40-hour a week job and you’re having to provide transportation, you’re having to give and manage heavy medication regimens,” Choula said. “You’re having to do this while you’re working, and that means that there could be potential impacts upon your work.” What does that look like?

“It means you may have to take off work more often. It may mean that you’re not able to move up the so-called ladder in your career because you’re having to be very focused in how you provide that care,” Choula said. “We hear this especially from millennial and Gen Z caregivers who really take a hard hit when it comes to being able to advance in their careers.”

Choula understands about the stresses and strains of caregiving, as she spent 15 years caring for a mother with a form of dementia called frontotemporal degeneration. “During that entire time I was working a full-time job,” Choula said. In the midst of caring for her mom, Choula gave birth to a daughter and son. “I had at one point a mother with dementia and two children under 2,” while maintaining a job, Choula said.

Nearly half of caregivers report at least one negative financial impact from their care responsibilities, including one-third who have stopped saving money and one-quarter who have run through their short-term savings, the report says. All this increases the amount of stress placed on family caregivers. Nearly two-thirds (64%) reported high emotional stress, while another 45% reported heavy physical strain, the report found.

The AARP has advocated a number of changes that could better support family caregivers, including federal and state tax credits to support their out-of-pocket expenses, Choula said. The group also supports a recent move by the Centers for Medicare and Medicaid Services to pay health care providers to give family caregivers training they need, Choula added.

Finally, family caregivers could be immensely aided by any efforts to help them coordinate their loved one’s medical care, Choula said. “My person has been in the hospital for several days and it comes time for them to be discharged,” Choula said. “Well, all of a sudden that family caregiver becomes the most popular person in the room because they’re going to be the one that is taking that person home.”

The caregiver now must become a “master coordinator,” she said, arranging follow-ups with specialists, tracking new medications, coordinating insurance payments and the like. “Those are some of the invisible things that family caregivers are having to face every day, in addition to working and caring for their children,” Choula said.

She recommends that caregivers reach out to Aging and Disability Resource Centers, programs across the country that are able to refer them to resources in their community.

“At the end of the day, caregivers need help, and the more caregivers take on and the more newer caregivers that we get, the more they’re going to be seeking these resources,” Choula said.

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As Pickleball’s Popularity Surges, Injuries Are Also on the Rise

February 8, 2024
Annie Pierce, UC San Diego

Avid pickleball player Carole Harland says doing dynamic warmups and stretching pre-game is a key to staying injury-free on the court.  America’s fastest-growing sport with the silly name – pickleball – continues to lure new players onto courts in droves. But before hopping into the game, UC San Diego Health physical therapists recommend acing a pickleball pre-game routine to help keep injuries at bay. 

“It’s a fun and addictive sport that you can pick up easily and immediately start playing,” said Aaron Cortez, DPT, physical therapist at UC San Diego Health who has seen an uptick in pickleball injuries among his patients. “Yet it’s a fast-moving game with sudden starts and stops – so it’s easy to get injured if you haven’t run or moved that quickly in years, or maybe even decades.”

“It’s crucial to prepare yourself for those explosive movements before stepping foot onto the court,” he said, adding that the sport is particularly popular among older adults.

Pickleball, a mash-up of ping-pong, tennis and badminton, has clinched the top spot as the fastest growing sport in the country for three years running, with 8.9 million players in the United States in 2023, according to the Sports & Fitness Industry Association, up from 4.8 million in 2022. That number is expected to surge beyond 20 million this year. 

With celebrities from Tom Brady to Leonardo DiCaprio heightening the hype of the game, its unprecedented growth is also causing a steep surge in injuries. Pickleball injuries generated more than $350 million in medical costs in 2023, as reported by Bloomberg, citing research by UBS analysts. The analysts estimated there would be more than 66,750 emergency department visits and 366,000 outpatient visits from pickleball in 2023, based on research from a Journal of Emergency Medicine study about pickleball and tennis-related injuries. The most common types of injuries reported are sprains, strains and fractures, and patients aged 50 or older account for 90% of the injuries. 

During the pandemic, pickleball’s popularity skyrocketed when people discovered they could escape lockdown by learning to play a fun new game while staying socially distanced outdoors. But why all the injuries?  Kenneth Vitale, MD, a physical medicine and rehabilitation physician at UC San Diego Health, said many pickleball players already have baseline arthritis due to their age.

“When you have arthritis and then further aggravate it with twisting or trauma, the arthritis can flare up. Also, ‘picklers’ are notorious for not warming up and for continuing to play through an injury, which can progress their arthritis and eventually require joint replacement surgery,” Vitale said.

Relishing pre-game preparation

Although the growing number of injuries are causing quite a racket, pickleball addicts say they’re not about to shy away from the court. Carole Harland said it was love at first swing when a friend invited her to play pickleball seven years ago. She had been on a weight loss and exercise journey, going to the gym three days a week and walking. 

“But once I discovered pickleball that was it. I dropped the gym and just started playing pickleball nonstop. It’s a game where you can just jump in – the hardest part is keeping score and staying out of the ‘kitchen,’” Harland said with a laugh, referring to the non-volley zone of a pickleball court.  Harland had suffered with knee arthritis for years and underwent a full knee replacement in May 2023. She teamed up with Cortez for physical therapy to help rebuild her strength and agility before returning to the court.

“Through physical therapy, my range of motion has improved, and I’ve gradually been able to increase how often I can play,” said Harland, who also teaches pickleball introductory classes at Poway Adult School. “Doing dynamic warm-ups and stretching is really important because your body has to be prepared and ready for the quick movements.”

Cortez said Harland’s newfound respect for prehab exercises has been the key to both her recovery and keeping her injury free post-surgery. To help others do the same, Cortez and Chris Rudd, DPT, physical therapist at UC San Diego Health, have served up a series of prehab exercises to help prepare both novice and seasoned players alike for the explosive movements of the sport.

An avid pickleball player himself, Cortez says there’s a lot to love about the game. With a good warm-up, wearing the correct shoes (tennis, not running shoes) and refraining from straining to return a ball or running backwards, pickleball can be a great way to burn calories and lead an active life.

“It checks a lot of boxes for people of all ages and backgrounds, blending social and physical activity,” Cortez said. “There’s never been a sport quite like it that has such an intergenerational component where you have teens and seniors playing together. Plus, the average 150-pound person can burn 400 to 500 calories an hour, so it can be a great workout.”

Warming up is a big dill

Going from the couch to the court is a recipe for disaster, said Cortez and Rudd. Yet that’s what many pickleball players expect their bodies to do. Instead, begin by warming up the body with jumping jacks, jogging or another cardiovascular activity pre-game.

Next, focus on functional movements instead of static movements. Doing forward, reverse and lateral lunges can help prepare the legs and joints for the variety of movements during play. Warming up the shoulders, wrists, ankles and Achilles tendons are also key, along with doing planks for core stability and strength. 

“It’s also important to play smart – ideally you shouldn’t be playing multiple days in a row, because that can cause overuse injuries. You want to gradually ramp up to the activity and not suddenly become obsessed, because the body just isn’t used to that level of repetition,” Cortez said, adding that cross training, balance and flexibility training are also recommended. 

Harland said a great way to avoid injuries is to take an introductory class instead of learning the game on the fly.  “If you start with the foundation of learning the basics and learning what not to do – like running backwards – you won’t develop bad habits,” she said. “Pickleball is a very social, family-oriented game where there’s just so much laughter and fun. I don’t ever plan on giving it up!”

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Is Downsizing in Retirement the Right Financial Move?

Downsizing your home in retirement might seem like the most straightforward way to cut costs and access the home’s equity. With rising property taxes, utility bills and home maintenance expenses, it’s unsurprising that a big house can feel more like a burden than a haven in your golden years. But is downsizing the best option?

While moving to a smaller space can benefit some, it’s not the only way to improve your financial flexibility in retirement. From reverse mortgages to life insurance settlements, several retirement cash flow options are worth exploring before listing your home. Below, we go over what to consider before moving – and alternatives if you decide to stay put.

SHOULD YOU DOWNSIZE IN RETIREMENT? 5 QUESTIONS TO ASK

Before making retirement housing decisions, consider whether downsizing aligns with your financial and lifestyle goals. These questions can help you assess your options:

  • Do you truly need the space you have now? Unused rooms and high maintenance demands may signal it’s time to simplify. Downsizing could free you from upkeep you no longer want or need.
  • Will you actually save money after the move? Factor in transaction costs, moving expenses and new home prices. Downsizing doesn’t always lower your monthly costs, especially in high-demand areas.
  • Will a new home improve your lifestyle? Think about access to family, medical care or walkable amenities. The right move can enhance your day-to-day comfort and convenience.
  • Are you emotionally ready to let go? Letting go of a long-time home can be harder than expected. Make sure the timing feels right for you and your family.
  • Have you considered other retirement cash flow options? From HELOCs to life insurance settlements, there may be ways to increase income or liquidity without moving. Downsizing for retirement income isn’t your only path forward.

DOWNSIZING: THE PROS AND POTENTIAL PAYOFF

The main appeal of downsizing is the chance to unlock equity from your home and reduce ongoing costs. Here’s a closer look at these advantages and more.

  • Free up retiree home equity: If you own your home outright or have significant equity, selling could provide a lump sum to supplement retirement savings, cover medical costs or delay Social Security benefits.
  • Lower housing costs: Smaller homes often mean lower property taxes, utility bills, homeowners insurance and upkeep costs. This frees up room in your monthly budget.
  • Be closer to support: Some retirees move closer to family, doctors or age-friendly amenities. It opens the door to better healthcare access, a more favorable tax environment, walkable communities and public transit.
  • Simplify daily life: A smaller, more accessible home can reduce physical strain and daily responsibilities, particularly for retirees with mobility concerns. It can also be a fresh start, physically and emotionally.
  • Avoid future upkeep: As homes age, so do their systems. Downsizing can help avoid hefty repair bills for roofs, HVAC systems and plumbing.

DOWNSIZING: THE CONS AND HIDDEN COSTS

For all its potential, downsizing your home in retirement comes with trade-offs that are easy to overlook until you’re in the thick of it. Here are a few downsizing retirement pitfalls to consider.

  • Upfront expenses can be high: Selling your home in retirement and buying another involves agent commissions, legal fees, moving costs and potentially new furniture or renovations. These costs can eat into your proceeds.
  • Market conditions matter: In some areas, downsizing doesn’t mean downgrading your budget. Per-square-foot costs can be higher for smaller homes or single-story properties in high-demand retirement markets.
  • Loss of space and flexibility: Hosting family gatherings and out-of-town guests or storing hobbies and keepsakes becomes harder in a smaller space. You may lose the flexibility your current home provides.
  • Emotional strain: Selling a family home can be an emotional hurdle, especially if it’s filled with memories.

OTHER WAYS TO UNLOCK VALUE IN RETIREMENT

If downsizing doesn’t feel like the right fit, or if you want to avoid a major move, there are several alternatives to downsizing that can help improve your retirement cash flow:

  • Home equity lines of credit (HELOCs): A HELOC allows you to borrow against your home’s value while keeping it. However, it requires ongoing payments and strong credit.
  • Reverse mortgages: These can offer steady cash flow, but fees and interest can reduce long-term equity.
  • House hacking for retirees: Renting out a room, basement or guesthouse can generate retirement income with minimal disruption.
  • Life insurance settlements: If you no longer need your policy or premiums have become unaffordable, selling it may provide a lump sum worth significantly more than the surrender value. This can be a low-disruption way to access value from an underused asset.
  • Asset reallocation: Revisiting your investment portfolio or consolidating accounts can reveal untapped resources or reduce fees, improving income sustainability.
  • Important: Many strategies to unlock retiree home equity, such as downsizing, reverse mortgages or life insurance settlements, can increase liquid assets. Consult a financial advisor to avoid unintended eligibility issues if you rely on Medicaid or other need-based assistance.

WHEN DOWNSIZING ISN’T A CHOICE

Not every retiree downsizes by choice. Sometimes it’s a decision driven by rising costs, unexpected health issues, or a change in income. A house that once felt comfortable and manageable may start to feel overwhelming – physically, financially or both. In these situations, downsizing can feel like a loss, especially when the move is about making ends meet rather than starting fresh.

That’s why it’s worth exploring all your options before packing up. There may be other ways to improve your cash flow, like tapping into home equity or selling a life insurance policy you no longer need. If downsizing feels more like a last resort than a new beginning, those alternatives might help you stay in the home you love a little longer.

RIGHTSIZING YOUR RETIREMENT PLAN

Downsizing can offer real benefits, especially for retirees looking to simplify or improve their finances. But other retirees prefer to stay in their homes and explore options like HELOCs, partial rentals or life settlements. These can offer similar results with less disruption. Whether you adjust your square footage or rethink your finances, take time to explore all your options. A strong retirement plan should fit your life, not vice versa.

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10 Big Medicare Changes in 2026: Higher Premiums, Drug Price Drops, and Looming Program Cuts

By Jeanine Skowronski

 Published August 28, 2025

Medicare rules, costs, and benefits change every year, but some coming up in 2026 could have a bigger impact on your health and your wallet than usual. Along with having to pay fairly standard price increases, you may be affected by uncertainty across the health insurance market because of changes related to the “One Big Beautiful Bill Act” have created. These ripple effects may make your plan choices and access to care more complicated. Here’s what to know about the major ways Medicare is changing in 2026 and how it might affect your coverage. 

Key Takeaways

  • Medicare Part B and Part D prices will rise, with some increases hitting double digits. 
  • You’ll face slightly higher maximum out-of-pocket drug costs, but new negotiated drug prices could save you on insulin and other expensive drugs.
  • Medicare Advantage plans are scaling back on extra perks, while Original Medicare is testing new prior-approval requirements, introducing new trade-offs.
  • Recent Medicaid cutbacks could directly impact people who qualify for both Medicare and Medicaid, and indirectly affect all Medicare users.    
  • Open enrollment starts October 15. Prepare by reviewing these changes, exploring all options, and consulting with a Medicare expert.

1. You’ll Pay More for Medicare Parts B and D 

Premiums for Medicare Part B (medical insurance that helps pay for doctor visits and medical equipment) are projected to rise 11.6%, from $185 to $206.50, while Part D (optional prescription drug coverage) base beneficiary premiums are expected to increase by an estimated 6% on average, from $36.78 to $38.99. 

But the base beneficiary premium is just the starting place for calculating the plan-specific premiums. Part D plans are offered by private companies, which haven’t yet released the actual premiums. Yours could be higher or lower than the base beneficiary premium. Many Part D plans, especially those offered with Medicare Advantage plans, have $0 premiums. 

Other costs are getting more expensive, too, with Part B’s deductible expected to rise by 12%, from $257 to $288, and Part D’s deductible slated to go from $590 to $615.

Medicare year-over-year cost increases aren’t new. They’re typically tied to inflation – specifically, the rising cost of health care. (Last year, the Part B premium increased by $10.30.) Still, the cost hikes can strain budgets, particularly for cash-strapped seniors.

2. Part D’s Catastrophic Threshold Is Going Up

The Inflation Reduction Act (IRA) instituted a cap on out-of-pocket drug costs for people with Medicare Part D. This catastrophic threshold is similar to an out-of-pocket maximum in other health plans, but it just applies to prescription drugs. After you meet it, the plan pays 100% of your costs. The threshold will increase in 2026 from $2,000 to $2,100. 

3. It’ll Get Easier to Participate in Prescription Payment Plans

Last year, you had the chance to sign up for the Medicare Prescription Payment Plan (MPPP), which allows you to spread your out-of-pocket drug costs across the calendar year instead of paying everything at once at the pharmacy if you have a Part D plan. 

This year, if you sign up for the payment plan, it’s going to be easy to keep the payment plan going in the future without having to think about it. If you enroll in 2026, you’ll automatically stay enrolled in 2027 unless you opt out. You’ll get a renewal notice at the end of each election period outlining any new terms and conditions. If you decide to leave, providers must process your request within three calendar days.   

4. Your Medicare Advantage Plan Might Have Fewer Supplemental Benefits

Beginning in 2026, Medicare Advantage (MA) Plans, a long-time alternative to Original Medicare, are getting new guardrails on what they can offer under Special Supplemental Benefits for the Chronically Ill (SSBCI). SSBCI are non-medical benefits that are supposed to contribute to the well-being and functioning of people with certain chronic conditions. Now, they must exclude: 

  • Non-healthy food
  • Alcohol
  • Tobacco
  • Life insurance

The new provisions continue a trend that has seen private insurers pare back MA plan supplemental benefits, including for over-the-counter medications, transportation services, nutrition services, and meals, in recent years.  

5. You Might Face Prior Authorization Requirements for Original Medicare

Six states—Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington – will test a new model that effectively requires you to get pre-authorization for an expanded set of services if you have Original Medicare (Parts A and B). In other words, Medicare must approve the treatment before you can get care.

These services include, but are not limited to, skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis. They exclude inpatient and emergency services. Historically, Original Medicare only required pre-authorization for durable medical equipment and certain outpatient hospital department services. 

Prior authorization rules are already common among Medicare Advantage plans, with 99% of enrollees shouldering prior authorization requirements for at least some services, including hospital stays, nursing facility stays, and chemotherapy. 

 In response to growing scrutiny, UnitedHealthcare pledged to cut 10% of its prior authorization requirements this year, following a lawsuit alleging it used artificial intelligence to unfairly deny care to Medicare Advantage patients. Similarly, the Trump Administration encouraged a coalition of major health insurers to commit to reforming the prior authorization process and reducing the number of claims subject to prior authorization by January 1, 2026. Clearly, this is not the last we’ll hear about changes in prior authorization policies.

6. 10 Negotiated Drug Prices Should Fall – With More Price Cuts to Come

The Inflation Reduction Act gave Medicare the authority to directly negotiate the price of high-cost, single-source drugs with pharmaceutical manufacturers. Previously, it relied on commercial prices set by private health insurance companies. In 2026, the first set of negotiated prices will take effect. They apply to the following prescriptions: 

  • Eliquis
  • Enbrel
  • Entresto
  • Farxiga
  • Imbruvica
  • Januvia 
  • Jardiance
  • Fiasp/NovoLog
  • Stelara
  • Xarelto

Given that the list of drugs is relatively short, next year’s cost savings may be minimal – and the program’s long-term effects remain hard to gauge. Broadly speaking, however, “the price negotiation program, combined with other provisions of the [IRA] is expected to make prescription drugs more affordable for millions of seniors, particularly those with high medication costs,” said Luke Eckley,chief revenue officer at Apollo Insurance Group. 

The Centers for Medicaid and Medicare (CMS) announced in January that its 2027 slate of 15 drugs for price negotiations would include weight loss drugs Ozempic, Rybelsus, and Wegovy. 

7. Insulin Costs Could Drop Even More

The IRA introduced a hard $35 cap on what you pay for monthly insulin supplies covered under Part B and Part D back in 2023. It also required insulin to be covered before you meet your deductible. Starting in January 2026, this cap gets more flexible to allow for deeper savings, with Medicare enrollees paying the lesser of:

  • $35
  • 25% of the maximum fair price established for the covered insulin product under the Medicare Drug Price Negotiation Program; or
  • 25% of the negotiated price under the standalone Medicare prescription drug plan (PDP) or MA plan with prescription drug coverage (MA-PD plan).

8. You’re Still Eligible for Free Vaccines, Though They May Be Harder to Come By

In 2023, the IRA eliminated deductibles, copays, and coinsurance for all adult vaccines recommended by the Advisory Committee for Immunization Practices (ACIP). This rule will stay in effect in 2026. However, there is uncertainty as to whether the current list, which includes the COVID-19, RSV, and Shingles vaccines, will change. ​

9. Some Dual-Eligible Enrollees Will Lose Access to Medicaid and Medicare

The GOP’s big bill introduced stringent work and enrollment requirements for all Medicaid recipients.  OBBBA exempts seniors 65 and over or with disabilities from work requirements, but if you’re in this group, you still must follow new enrollment and eligibility verification rules. The administrative burden of meeting these requirements every six months could prove too much for some people, especially those with disabilities. That could cost them their Medicaid coverage, even though they’re eligible for it.

Medicaid “covers a range of services that Medicare does not, such as long-term care, home and community-based services, dental, vision, and hearing care,” Eckley said. “The loss of Medicaid would mean losing access to these critical benefits.”

The OBBBA also delayed the implementation of a Biden administration rule aimed at reducing barriers to enrollment in the Medicare Savings Programs (MSPs), which allow Medicaid to cover Medicare premiums and other out-of-pocket expenses for low-income individuals.

So, even if you are able to keep your Medicaid plan, if you’re not able to enroll in the MSP and receive the subsidies, you could find you’re not able to afford Medicare. 

10. The Ballooning National Deficit Could Force Medicare Cuts

Trump’s megabill didn’t make many direct changes to Medicare, but its effects on the national deficit could trigger deep cuts to program funding. Expected to add $3.4 trillion to the deficit by 2034, the bill’s provisions could lead to the “sequester cliff,” which triggers automatic spending cuts under the Pay-As-You-Go law once the deficit reaches a certain amount. 

Even if Congress addresses this issue, the bill’s drastic changes to the Medicaid program are expected to reduce access to health care by driving up health care costs, forcing reductions in services, and causing hospital closures.

How to Prepare for 2026 Medicare Enrollment

Medicare open enrollment begins Oct. 15 and runs until Dec. 7. During that time, you can join, drop, or switch Medicare Advantage or Part D drug plans. You can also return to Original Medicare from a Medicare Advantage plan.

You can navigate forthcoming changes to Medicare – and your health insurance – by taking these steps. 

  • Avoid blindly re-enrolling in your current plan, as it can change significantly year to year. You may feel very loyal to your plan, but then suddenly find out that its provider network has shrunk and your doctor is no longer included, Thompson said. Confirm that your plan still offers the best coverage for your area and budget compared to alternatives. 
  • Read the list of covered medications in Part D plans carefully. These lists are called formularies.“Medicare Part D plans and pharmacy benefit managers (PBMs) may need to re-evaluate their formularies and pricing strategies,” in light of negotiated drug prices, Eckley said. As a result, it’s essential to check if the medication you’re taking is covered before joining a plan in 2026. 
  • Seek assistance. Work with a Medicare insurance broker. An independent broker (one who doesn’t just work for one insurance company) can help you understand your options, particularly if you’re considering a switch from Medicare Advantage to Original Medicare plus a Medigap plan. 

The Bottom Line

On paper, the 2026 Medicare changes seem fairly routine. Premiums, deductibles, and other cost-sharing expenses tend to rise year-over-year, and some changes, such as negotiated drug prices and free vaccinations, simply expand or formally introduce provisions of the IRA. However, uncertainty looms, given the OBBBA’s impact on the national deficit and the health care system in general. Prepare for open enrollment by familiarizing yourself with the changes – and your options in best-or worst-case scenarios.