Severe Complications for Pregnant Veterans Nearly Doubled in the Last Decade, a GAO Report Finds

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Series: Post-Roe America:Abortion Access Divides the Nation

After the Supreme Court overturned Roe v. Wade, ending nearly 50 years of federal protection for abortion, some states began enforcing strict abortion bans while others became new havens for the procedure. ProPublica is investigating how sweeping changes to reproductive health care access in America are affecting people, institutions and governments.

Over the past decade, the rate of veterans suffering severe pregnancy complications has risen dramatically, a new federal report found.

Veterans have raced to the hospital with dangerous infections, kidney failure, aneurysms or blood loss. They’ve required hysterectomies, breathing machines and blood transfusions to save their lives. Between 2011 and 2020, 13 veterans died after such complications.

The report found that among people getting health care benefits through the Department of Veterans Affairs, the rate of severe complications nearly doubled during that time, from about 93 per 10,000 hospitalizations in 2011 to just over 184 per 10,000 hospitalizations in 2020. Black veterans had the highest rates.

The report, which was put together by the Government Accountability Office, also made recommendations for reducing the problem, which focus on conducting more routine screenings throughout pregnancy and in the postpartum period.

“It is imperative that the VA help ensure veterans have the healthiest pregnancy outcomes possible,” the report said, highlighting the increasing number of veterans using the agency’s maternity benefits as well as the troublesome complication rates faced by Black women.

The report’s findings are an unfortunate trend, said Alyssa Hundrup, director of health care at the GAO. The office analyzed data on 40,000 hospitalizations related to deliveries paid for by the VA. It captures a time period before 21 states banned or greatly restricted abortion and the military was thrust into a political battle over whether it would pay for active service members to travel for abortion care if a pregnancy was a risk to their health.

Hundrup, who led the review, said the analysis included hospital records from days after delivery to a year postpartum. The report was mandated after Congress passed a law in 2021 that aimed to address the maternal health crisis among veterans. The law led to a $15 million investment in maternity care coordination programs for veterans.

The report recommended that the VA analyze and collect more data on severe complications as well as data on the mental health, race and ethnicity of veterans who experience complications to understand the causes behind the increase and the reasons for the disparity. The report also states that oversight is needed to ensure screenings are being completed.

Studies show there’s a connection between mental health conditions and pregnancy-related complications, VA officials said.

The report recommended expanding the screening questions that providers ask patients at appointments to glean more information about their mental health, including anxiety and PTSD symptoms. It urged the VA to review the data more regularly.

“You don’t know what you don’t measure,” Hundrup said in an interview with ProPublica.

The VA health system, which historically served a male population, does not provide maternity care at its facilities. Instead, the agency has outsourced maternity care. But when patients were treated by those providers, the VA failed to track whether they were getting screened for other health issues and mental health problems.

Officials hope the improved data collection will help the VA study underlying issues that may lead to complications. For example, do higher rates of anxiety have a connection to rates of high blood pressure in pregnant people?

VA officials are working with a maternal health review committee to monitor the data as it is gathered. The agency recently conducted its first review of data going back five years about pregnancy-related complications, said Dr. Amanda Johnson, acting head of the VA’s Office of Women’s Health, who is overseeing the implementation of the report’s recommendations.

The VA has created a dashboard to monitor pregnant veterans’ health outcomes. The VA’s data analysis team will also examine the impact of veterans’ ages on complications and whether they differ for people who live in urban and rural areas.

VA officials will begin to review mental health screenings conducted by maternal care coordinators in March. The coordinators advocate for veterans, helping them between health care visits, whether their providers are inside or outside the VA.

Johnson said that reducing racial and ethnic disparities is a priority for the agency. In 2018, ProPublica published “Lost Mothers,” a series that shed light on the country’s maternal health crisis. Studies have shown that in the general population, Black women are three times more likely than white women to die from pregnancy-related complications. While deaths made up only a small portion of the bad outcomes for Black veterans cited in the report, VA care could not spare them from elevated rates of severe complications. Johnson said the maternal health crisis also persists within the VA.

“There is a disparity,” Johnson said. “We are not immune to that.”

Research shows pregnant people who have used the VA’s coverage have higher rates of trauma and mental conditions that can increase their risks of complications and bad outcomes.

This may be because many people who join the military enter it having already faced trauma, said Dr. Laura Miller, a psychiatrist and the medical director of reproductive mental health at the VA.

She said veterans with PTSD have higher rates of complications such as preeclampsia, a potentially fatal condition related to high blood pressure, gestational diabetes and postpartum depression. If untreated during pregnancy, depression also increases the likelihood of preterm birth and lingering problems for babies.

Hundrup said she hopes this proactive work will improve maternal health.

“We want these numbers trending in the other direction,” Hundrup said.

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  • Gut Health 2.0

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    Gene Expression & Gut Health

    Dr. Tim Spector, a renowned expert in Gut Health 2.0, offers valuable insights and expertise on the latest advancements in improving gut health and overall well-being. With years of research and

    This is Dr. Tim Spector. After training in medicine and becoming a consultant rheumatologist, he’s turned his attention to medical research, and is these days a specialist in twin studies, genetics, epigenetics, microbiome, and diet.

    What does he want us to know?

    For one thing: epigenetics are for more than just getting your grandparents’ trauma.

    More usefully: there are things we can do to improve epigenetic factors in our body

    DNA is often seen as the script by which our body does whatever it’s going to do, but it’s only part of the story. Thinking of DNA as some kind of “magical immutable law of reality” overlooks (to labor the metaphor) script revisions, notes made in the margins, directorial choices, and ad-lib improvizations, as well as the quality of the audience’s hearing and comprehension.

    Hence the premise of one of Dr. Spector’s older books, “Identically Different: Why We Can Change Our Genes

    (*in fact, it was his first, from all the way back in 2013, when he’d only been a doctor for 34 years)

    Gene expression will trump genes every time, and gene expression is something that can often be changed without getting in there with CRISPR / a big pair of scissors and some craft glue.

    How this happens on the micro level is beyond the scope of today’s article; part of it has to do with enzymes that get involved in the DNA transcription process, and those enzymes in turn are despatched or not depending on hormonal messaging—in the broadest sense of “hormonal”; all the body’s hormonal chemical messengers, not just the ones people think of as hormones.

    However, hormonal messaging (of many kinds) is strongly influenced by something we can control relatively easily with a little good (science-based) knowledge: the gut.

    The gut, the SAD, and the easy

    In broad strokes: we know what is good for the gut. We’ve written about it before at 10almonds:

    Making Friends With Your Gut (You Can Thank Us Later)

    This is very much in contrast with what in scientific literature is often abbreviated “SAD”, the Standard American Diet, which is very bad for the gut.

    However, Dr. Spector (while fully encouraging everyone to enjoy an evidence-based gut-healthy diet) wanted to do one better than just a sweeping one-size-fits-all advice, so he set up a big study with 15,000 identical twins; you can read about it here: TwinsUK

    The information that came out of that was about a lot more than just gene expression and gut health, but it did provide the foundation for Dr. Spector’s next project, ZOE.

    ZOE crowdsources huge amounts of data including individual metabolic responses to standardized meals in order to predict personalized food responses based on individual biology and unique microbiome profile.

    In other words, it takes the guesswork out of a) knowing what your genes mean for your food responses b) tailoring your food choices with your genetic expression in mind, and c) ultimately creating a positive feedback loop to much better health on all levels.

    Now, this is not an ad for ZOE, but if you so wish, you can…

    Want to know more?

    Dr. Spector has a bunch of books out, including some that we’ve reviewed previously:

    You can also check out our own previous main feature, which wasn’t about Dr. Spector’s work but was very adjacent:

    The Brain-Gut Highway: A Two-Way Street

    Enjoy!

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  • How To Engage Your Whole Brain

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    The Stroke Of Insight That Nobody Wants

    This is Dr. Jill Bolte Taylor. She’s a neuroanatomist, who, at the age of 37 (when she was a post-doctoral fellow at Harvard Medical School), had what she refers to as her “stroke of insight”.

    That is to say, she had a massive stroke, and after a major brain surgery to remove a clot the size of a golf ball, she spent the next 8 years re-learning to do everything.

    Whereas previously she’d been busy mapping the brain to determine how cells communicate with each other, now she was busy mapping whether socks or shoes should go on first. Needless to say, she got an insight into neuroplasticity that few people would hope for.

    What does she want us to know?

    Dr. Taylor (now once again a successful scientist, lecturer, and author) advocates for “whole brain living”, which involves not taking parts of our brain for granted.

    About those parts…

    Dr. Taylor wants us to pay attention to all the parts regardless of size, ranging from the two hemispheres, all the way down to the billions of brain cells, and yet even further, to the “trillions of molecular geniuses”—because each brain cell is itself reliant on countless molecules of the many neurochemicals that make up our brain.

    For a quick refresher on some of the key players in that latter category, see our Neurotransmitter Cheatsheet 😎

    When it comes to the hemispheres, there has historically been a popular belief that these re divided into:

    • The right brain: emotional, imaginative, creative, fluid feeling
    • The left brain: intellectual, analytical, calculating, crystal thinking

    …which is not true, anatomically speaking, because there are cells on both sides doing their part of both of these broad categories of brain processes.

    However, Dr. Taylor found, while one hemisphere of her brain was much more damaged than the other, that nevertheless she could recover some functions more quickly than others, which, once she was able to resume her career, inspired her model of four distinct ways of cogitating that can be switched-between and played with or against each other:

    Meet The Four Characters Inside Your Brain

    Why this matters

    As she was re-learning everything, the way forward was not quick or easy, and she also didn’t know where she was going, because for obvious reasons, she couldn’t remember, much less plan.

    Looking backwards after her eventual full recovery, she noted a lot of things that she needed during that recovery, some of which she got and some of which she didn’t.

    Most notably for her, she needed the right kind of support that would allow all four of the above “characters” as she puts it, to thrive and grow. And, when we say “grow” here we mean that literally, because of growing new brain cells to replace the lost ones (as well as the simple ongoing process of slowly replacing brain cells).

    For more on growing new brain cells, by the way, see:

    How To Grow New Brain Cells (At Any Age)

    In order to achieve this in all of the required brain areas (i.e., and all of the required brain functions), she also wants us to know… drumroll please

    When to STFU

    Specifically, the ability to silence parts of our brain that while useful in general, aren’t necessarily being useful right now. Since it’s very difficult to actively achieve a negative when it comes to brain-stuff (don’t think of an elephant), this means scheduling time for other parts of our brain to be louder. And that includes:

    • scheduling time to feel (emotionally)
    • scheduling time to feel (gut feelings)
    • scheduling time to feel (kinesthetically)

    …amongst others.

    Note: those three are presented in that order, from least basic to most basic. And why? Because, clever beings that we are, we typically start from a position that’s not remotely basic, such as “overthinking”, for example. So, there’s a wind-down through thinking just the right amount, thinking through simpler concepts, feeling, noticing one’s feelings, noticing noticing one’s feelings, all the way down to what, kinesthetically, are we actually physically feeling.

    ❝It is interesting to note that although our limbic system fucntions throughout our lifetime, it does not mature. As a result, when our emotional “buttons” are pushed, we retain the ability to react to incoming stimulation as though we were a two-year-old, even when we are adults.❞

    ~ Dr. Jill Taylor

    Of course, sometimes the above is not useful, which is why the ability to switch between brain modes is a very important and useful skill to develop.

    And how do we do that? By practising. Which is something that it’s necessary to take up consciously, and pursue consistently. When children are at school, there are (hopefully, ideally) curricula set out to ensure they engage and train all parts of their brain. As adults, this does not tend to get the same amount of focus.

    “Children’s brains are still developing”—indeed, and so are adult brains:

    The Brain As A Work-In-Progress

    Dr. Taylor had the uncommon experience of having to, in many ways, neurologically speaking, redo childhood. And having had a second run at it, she developed an appreciation of the process that most of us didn’t necessarily get when doing childhood just the once.

    In other words: take the time to feel stuff; take the time to quiet down your chatty mind, take the time engage your senses, and take it seriously! Really notice, as though for the first time, what the texture of your carpet is like. Really notice, as though for the first time, what it feels like to swallow some water. Really notice, as though for the first time, what it feels like to experience joy—or sadness, or comfort, or anger, or peace. Exercise your imagination. Make some art (it doesn’t have to win awards; it just has to light up your brain!). Make music (again, it’s about wiring your brain in your body, not about outdoing Mozart in composition and/or performance). Make changes! Make your brain work in the ways it’s not in the habit of doing.

    If you need a little help switching off parts of your brain that are being too active, so that you can better exercise other parts of your brain that might otherwise have been neglected, you might want to try:

    The Off-Button For Your Brain

    Enjoy!

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  • Tips for Improving Memory

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    Q&A with 10almonds Subscribers!

    Q: Any tips, other than supplements, for improving memory?

    A: So many tips! Certainly enough to do a main feature on, so again maybe we’ll do that in another issue soon. Meanwhile, here are the absolute most critical things for you to know, understand, and apply:

    • Memory is a muscle. Not literally, but in the sense that it will grow stronger if exercised and will atrophy if neglected.
    • Counterpart of the above: your memory is not a finite vessel. You can’t “fill it up with useless things”, so no need to fear doing so.
    • Your memory is the product of countless connections in your brain. The more connections lead to a given memory, the more memorable it will be. What use is this knowledge to you? It means that if you want to remember something, try to make as many connections to it as possible, so:
      • Involve as many senses as possible.
      • When you learn things, try to learn them in context. Then when your mind has reason to think about the context, it’ll be more likely to remember the thing itself too.
    • Rehearsal matters. A lot. This means repeatedly going over something in your head. This brings about the neural equivalent of “muscle memory”.
    • Enjoy yourself if you can. The more fun something is, the more you will mentally rehearse it, and the more mental connections you’ll make to it.

    Have a question you’d like to see answered here? Hit reply to this email, or use the feedback widget at the bottom! We always love to hear from you

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  • The Anti-Stress Herb That Also Fights Cancer

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    What does Rhodiola rosea actually do, anyway?

    Rhodiola rosea (henceforth, “rhodiola”) is a flowering herb whose roots have adaptogenic properties.

    In the cold, mountainous regions of Europe and Asia where it grows, it has been used in herbal medicine for centuries to alleviate anxiety, fatigue, and depression.

    What does the science say?

    Well, let’s just say the science is more advanced than the traditional use:

    ❝In addition to its multiplex stress-protective activity, Rhodiola rosea extracts have recently demonstrated its anti-aging, anti-inflammation, immunostimulating, DNA repair and anti-cancer effects in different model systems❞

    ~ Li et al. (2017)

    Nor is how it works a mystery, as the same paper explains:

    ❝Molecular mechanisms of Rhodiola rosea extracts’s action have been studied mainly along with one of its bioactive compounds, salidroside. Both Rhodiola rosea extracts and salidroside have contrasting molecular mechanisms on cancer and normal physiological functions.

    For cancer, Rhodiola rosea extracts and salidroside inhibit the mTOR pathway and reduce angiogenesis through down-regulation of the expression of HIF-1α/HIF-2α.

    For normal physiological functions, Rhodiola rosea extracts and salidroside activate the mTOR pathway, stimulate paracrine function and promote neovascularization by inhibiting PHD3 and stabilizing HIF-1α proteins in skeletal muscles❞

    ~ Ibid.

    And, as for the question of “do the supplements work?”,

    ❝In contrast to many natural compounds, salidroside is water-soluble and highly bioavailable via oral administration❞

    ~ Ibid.

    And as to how good it is:

    ❝Rhodiola rosea extracts and salidroside can impose cellular and systemic benefits similar to the effect of positive lifestyle interventions to normal physiological functions and for anti-cancer❞

    ~ Ibid.

    Source: Rhodiola rosea: anti-stress, anti-aging, and immunostimulating properties for cancer chemoprevention

    But that’s not all…

    We can’t claim this as a research review if we only cite one paper (even if that paper has 144 citations of its own), and besides, it didn’t cover all the benefits yet!

    Let’s first look at the science for the “traditional use” trio of benefits:

    When you read those, what are your first thoughts?

    Please don’t just take our word for things! Reading even just the abstracts (summaries) at the top of papers is a very good habit to get into, if you don’t have time (or easy access) to read the full text.

    Reading the abstracts is also a very good way to know whether to take the time to read the whole paper, or whether it’s better to skip onto a different one.

    • Perhaps you noticed that the paper we cited for anxiety was quite a small study.
      • The fact is, while we found mountains of evidence for rhodiola’s anxiolytic (antianxiety) effects, they were all small and/or animal studies. So we picked a human study and went with it as illustrative.
    • Perhaps you noticed that the paper we cited for fatigue pertained mostly to stress-related fatigue.
      • This, we think, is a feature not a bug. After all, most of us experience fatigue because of the general everything of life, not because we just ran a literal marathon.
    • Perhaps you noticed that the paper we cited for depression said it didn’t work as well as sertraline (a very common pharmaceutical SSRI antidepressant).
      • But, it worked almost as well and it had far fewer adverse effects reported. Bear in mind, the side effects of antidepressants are the reason many people avoid them, or desist in taking them. So rhodiola working almost as well as sertraline for far fewer adverse effects, is quite a big deal!

    Bonus features

    Rhodiola also putatively offers protection against Alzheimer’s disease, Parkinson’s disease, and cerebrovascular disease in general:

    Rosenroot (Rhodiola): Potential Applications in Aging-related Diseases

    It may also be useful in the management of diabetes (types 1 and 2), but studies so far have only been animal studies, and/or in vitro studies. Here are two examples:

    1. Antihyperglycemic action of rhodiola-aqeous extract in type 1 diabetic rats
    2. Evaluation of Rhodiola crenulata and Rhodiola rosea for management of type 2 diabetes and hypertension

    How much to take?

    Dosages have varied a lot in studies. However, 120mg/day seems to cover most bases. It also depends on which of rhodiola’s 140 active compounds a particular benefit depends on, though salidroside and rosavin are the top performers.

    Where to get it?

    As ever, we don’t sell it (or anything else) but here’s an example product on Amazon.

    Enjoy!

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  • Uric Acid’s Extensive Health Impact (And How To Lower It)

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    Uric Acid’s Extensive Health Impact (And How To Lower It)

    This is Dr. David Perlmutter. He’s a medical doctor, and a Fellow of the American College of Nutrition. He’s a member of the Editorial Board for the Journal of Alzheimer’s Disease, and has been widely published in many other peer-reviewed journals.

    What does he want us to know?

    He wants us to know about the health risks of uric acid (not something popularly talked about so much!), and how to reduce it.

    First: what is it? Uric acid is a substance we make in our own body. However, unlike most substances we make in our body, we have negligible use for it—it’s largely a waste product, usually excreted in urine.

    However, if we get too much, it can build up (and crystallize), becoming such things as kidney stones, or causing painful inflammation if it shows up in the joints, as in gout.

    More seriously (unpleasant as kidney stones and gout may be), this inflammation can have a knock-on effect triggering (or worsening) other inflammatory conditions, ranging from non-alcoholic fatty liver disease, to arthritis, to dementia, and even heart problems. See for example:

    How can we reduce our uric acid levels?

    Uric acid is produced when we metabolize purine nucleotides, which are found in many kinds of food. We can therefore reduce our uric acid levels by reducing our purine intake, as well as things that mess up our liver’s ability to detoxify things. Offsetting the values for confounding variables (such as fiber content, or phytochemicals that mitigate the harm), the worst offenders include…

    Liver-debilitating things:

    • Alcohol (especially beer)
    • High-fructose corn syrup (and other fructose-containing things that aren’t actual fruit)
    • Other refined sugars
    • Wheat / white flour products (this is why beer is worse than wine, for example; it’s a double-vector hit)

    Purine-rich things:

    • Red meats and game
    • Organ meats
    • Oily fish, and seafood (great for some things; not great for this)

    Some beans and legumes are also high in purines, but much like real fruit has a neutral or positive effect on blood sugar health despite its fructose content, the beans and legumes that are high in purines, also contain phytochemicals that help lower uric acid levels, so have a beneficial effect.

    Eggs (consumed in moderation) and tart cherries have a uric-acid lowering effect.

    Water is important for all aspects of health, and doubly important for this.

    Hydrate well!

    Lifestyle matters beyond diet

    The main key here is metabolic health, so Dr. Perlmutter advises the uncontroversial lifestyle choices of moderate exercise and good sleep, as well as (more critically) intermittent fasting. We wrote previously on other things that can benefit liver health:

    How To Unfatty A Fatty Liver

    …in this case, that means the liver gets a break to recuperate (something it’s very good at, but does need to get a chance to do), which means that while you’re not giving it something new to do, it can quickly catch up on any backlog, and then tackle any new things fresh, next time you start eating.

    Want to know more about this from Dr. Perlmutter?

    You might like his article:

    An Integrated Plan for Lowering Uric Acid ← more than we had room for here; he also talks about extra things to include in your diet/supplementation regime for beneficial effects!

    And/or his book:

    Drop Acid: The Surprising New Science of Uric Acid―The Key to Losing Weight, Controlling Blood Sugar, and Achieving Extraordinary Health

    …on which much of today’s main feature was based.

    Take care!

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  • Older Americans Say They Feel Trapped in Medicare Advantage Plans

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    In 2016, Richard Timmins went to a free informational seminar to learn more about Medicare coverage.

    “I listened to the insurance agent and, basically, he really promoted Medicare Advantage,” Timmins said. The agent described less expensive and broader coverage offered by the plans, which are funded largely by the government but administered by private insurance companies.

    For Timmins, who is now 76, it made economic sense then to sign up. And his decision was great, for a while.

    Then, three years ago, he noticed a lesion on his right earlobe.

    “I have a family history of melanoma. And so, I was kind of tuned in to that and thinking about that,” Timmins said of the growth, which doctors later diagnosed as malignant melanoma. “It started to grow and started to become rather painful.”

    Timmins, though, discovered that his enrollment in a Premera Blue Cross Medicare Advantage plan would mean a limited network of doctors and the potential need for preapproval, or prior authorization, from the insurer before getting care. The experience, he said, made getting care more difficult, and now he wants to switch back to traditional, government-administered Medicare.

    But he can’t. And he’s not alone.

    “I have very little control over my actual medical care,” he said, adding that he now advises friends not to sign up for the private plans. “I think that people are not understanding what Medicare Advantage is all about.”

    Enrollment in Medicare Advantage plans has grown substantially in the past few decades, enticing more than half of all eligible people, primarily those 65 or older, with low premium costs and perks like dental and vision insurance. And as the private plans’ share of the Medicare patient pie has ballooned to 30.8 million people, so too have concerns about the insurers’ aggressive sales tactics and misleading coverage claims.

    Enrollees, like Timmins, who sign on when they are healthy can find themselves trapped as they grow older and sicker.

    “It’s one of those things that people might like them on the front end because of their low to zero premiums and if they are getting a couple of these extra benefits — the vision, dental, that kind of thing,” said Christine Huberty, a lead benefit specialist supervising attorney for the Greater Wisconsin Agency on Aging Resources.

    “But it’s when they actually need to use it for these bigger issues,” Huberty said, “that’s when people realize, ‘Oh no, this isn’t going to help me at all.’”

    Medicare pays private insurers a fixed amount per Medicare Advantage enrollee and in many cases also pays out bonuses, which the insurers can use to provide supplemental benefits. Huberty said those extra benefits work as an incentive to “get people to join the plan” but that the plans then “restrict the access to so many services and coverage for the bigger stuff.”

    David Meyers, assistant professor of health services, policy, and practice at the Brown University School of Public Health, analyzed a decade of Medicare Advantage enrollment and found that about 50% of beneficiaries — rural and urban — left their contract by the end of five years. Most of those enrollees switched to another Medicare Advantage plan rather than traditional Medicare.

    In the study, Meyers and his co-authors muse that switching plans could be a positive sign of a free marketplace but that it could also signal “unmeasured discontent” with Medicare Advantage.

    “The problem is that once you get into Medicare Advantage, if you have a couple of chronic conditions and you want to leave Medicare Advantage, even if Medicare Advantage isn’t meeting your needs, you might not have any ability to switch back to traditional Medicare,” Meyers said.

    Traditional Medicare can be too expensive for beneficiaries switching back from Medicare Advantage, he said. In traditional Medicare, enrollees pay a monthly premium and, after reaching a deductible, in most cases are expected to pay 20% of the cost of each nonhospital service or item they use. And there is no limit on how much an enrollee may have to pay as part of that 20% coinsurance if they end up using a lot of care, Meyers said.

    To limit what they spend out-of-pocket, traditional Medicare enrollees typically sign up for supplemental insurance, such as employer coverage or a private Medigap policy. If they are low-income, Medicaid may provide that supplemental coverage.

    But, Meyers said, there’s a catch: While beneficiaries who enrolled first in traditional Medicare are guaranteed to qualify for a Medigap policy without pricing based on their medical history, Medigap insurers can deny coverage to beneficiaries transferring from Medicare Advantage plans or base their prices on medical underwriting.

    Only four states — Connecticut, Maine, Massachusetts, and New York — prohibit insurers from denying a Medigap policy if the enrollee has preexisting conditions such as diabetes or heart disease.

    Paul Ginsburg is a former commissioner on the Medicare Payment Advisory Commission, also known as MedPAC. It’s a legislative branch agency that advises Congress on the Medicare program. He said the inability of enrollees to easily switch between Medicare Advantage and traditional Medicare during open enrollment periods is “a real concern in our system; it shouldn’t be that way.”

    The federal government offers specific enrollment periods every year for switching plans. During Medicare’s open enrollment period, from Oct. 15 to Dec. 7, enrollees can switch out of their private plans to traditional, government-administered Medicare.

    Medicare Advantage enrollees can also switch plans or transfer to traditional Medicare during another open enrollment period, from Jan. 1 to March 31.

    “There are a lot of people that say, ‘Hey, I’d love to come back, but I can’t get Medigap anymore, or I’ll have to just pay a lot more,’” said Ginsburg, who is now a professor of health policy at the University of Southern California.

    Timmins is one of those people. The retired veterinarian lives in a rural community on Whidbey Island just north of Seattle. It’s a rugged, idyllic landscape and a popular place for second homes, hiking, and the arts. But it’s also a bit remote.

    While it’s typically harder to find doctors in rural areas, Timmins said he believes his Premera Blue Cross plan made it more challenging to get care for a variety of reasons, including the difficulty of finding and getting in to see specialists.

    Nearly half of Medicare Advantage plan directories contained inaccurate information on what providers were available, according to the most recent federal review. Beginning in 2024, new or expanding Medicare Advantage plans must demonstrate compliance with federal network expectations or their applications could be denied.

    Amanda Lansford, a Premera Blue Cross spokesperson, declined to comment on Timmins’ case. She said the plan meets federal network adequacy requirements as well as travel time and distance standards “to ensure members are not experiencing undue burdens when seeking care.”

    Traditional Medicare allows beneficiaries to go to nearly any doctor or hospital in the U.S., and in most cases enrollees do not need approval to get services.

    Timmins, who recently finished immunotherapy, said he doesn’t think he would be approved for a Medigap policy, “because of my health issue.” And if he were to get into one, Timmins said, it would likely be too expensive.

    For now, Timmins said, he is staying with his Medicare Advantage plan.

    “I’m getting older. More stuff is going to happen.”

    There is also a chance, Timmins said, that his cancer could resurface: “I’m very aware of my mortality.”

    KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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