David Howard , 2025-04-29 08:30:00
Lost amid the turmoil of DOGE’s federal workforce cuts was a mid-February executive order directing DOGE to repeal regulations that impede innovation, are overly burdensome, or not clearly authorized by statute.
Now it appears that DOGE and the Trump administration are taking action on that order. The administration has even created a website, regulations.gov, where members of the public can suggest regulations to revoke.
MAGA-loathed regulations restricting energy production and auto emissions will probably be first on the chopping block, but DOGE also ought to take a close look at the Medicare program. While Medicare is mainly a spending program, it also exerts vast power over the health care system via the regulations that dictate how providers are paid and “conditions of participation,” the minimum criteria providers need to meet to treat Medicare patients.
Medicare’s “alternative payment models” tie provider payment to quality measures. Providers who do not buy expensive systems and hire staff to document quality measures risk sizeable reductions in Medicare payments. Many quality measures are only loosely related to actual patient outcomes, and the Biden administration used the quality measurement program to advance unrelated priorities. For example, eye doctors may receive lower Medicare payments if they fail to counsel patients to stop smoking. Dermatologists can be dinged if they do not screen patients for “food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.”
Addressing these quality-based payment incentives diverts physicians’ attention from patients’ most pressing needs and increases the time they spend documenting visits in the medical record. One study estimated that the annual compliance cost is nearly $13,000 per physician, and many physicians have responded to Medicare’s onerous requirements by abandoning independent practice for employment in large health systems.
But hospitals and large health systems are also facing greater regulatory burdens. Following an update to Medicare’s Hospital Inpatient Quality Reporting program, hospitals are required as of 2024 to attest that their strategic plan “identifies health equity goals and discrete action steps to achieving these goals” and “outlines specific resources which have been dedicated to achieving our equity goals.” Hospitals must stratify performance indicators by race, income, and other “social determinants of health variables” and report results on hospital dashboards. Hospital executives and trustees must create and review a health equity plan annually along with performance measures “stratified by demographic and/or social risk factors.” Hospitals may also “voluntarily” report greenhouse emissions to Medicare and take steps to “enhance organizational sustainability.”
Disparities in health outcomes between groups are large and deserving of attention. However, these requirements are rooted in a mindset that the main obstacle to progress is the lack of the appropriate form, report, or training. But the government offers little evidence to support these requirements, many of which will inevitably devolve into pro forma box checking that takes up valuable staff time but does little to improve patient outcomes.
A related regulation released in April 2024 requires Medicare Advantage plans, the private insurers that cover one-half of Medicare beneficiaries, to include an expert in health equity on the committees that review plans’ coverage policies. What qualifies one as an expert? The regulation provides some examples, such as having an “educational degrees or credentials with an emphasis on health equity” or “leading advocacy efforts to achieve health equity.”
These regulations come on top of other new rules that require providers to participate in complex payment models and mandate staffing levels and training for nursing homes and hospital’s obstetrical units. Surprisingly, there has been little pushback from the health care industry, perhaps because the regulations have been introduced on a piecemeal basis are often buried in the long, complex annual regulatory updates to Medicare payment policies. Few physicians or administrators have the time or inclination to wade through the dense, acronym-filled text. Administrators may worry about blowback if they oppose policies supported by regulators or advocacy groups.
As single payer advocates never tire of pointing out, the Medicare program has low administrative costs compared with private insurers. But, increasingly, the program shifts administrative costs to providers. A focused effort to deregulate an industry that accounts for 18% of the economy will pay large dividends.
David Howard is a professor of health policy and management at Emory University’s Rollins School of Public Health.
