Dr. Benjamin Jin, a biologist working on immunotherapy for HPV+ cancers, holds test tubes as he works in the lab of Dr. Christian Hinrichs, an investigator at the National Cancer Institute at the National Institutes of Health (NIH) in Bethesda, Maryland. – (Photo by SAUL LOEB / AFP) (Photo by SAUL LOEB/AFP via Getty Images)
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Now that Dr. Mehmet Oz is in place to lead the Centers for Medicare and Medicaid Services (CMS), he must quickly and directly tackle one of the greatest threats to preventative and individualized care in our country: Medicare Administrative Contractors (MACs). Oz’s decades of experience as a physician and cardiac surgeon will be critical.
MACs, under the purview of CMS, are private health insurance companies that administer Medicare claims. While their purpose is to “improve efficiency,” they’ve done everything but that. MACs serve as an unaccountable middleman between patients and doctors, driving up costs and worsening patient outcomes. They have repeatedly used their authority to make broad-sweeping decisions about coverage that prevent patients—especially seniors—from accessing vital preventative care such as genetic testing for cancer.
There’s an urgent need to tackle illness and chronic diseases at their core, and embracing early intervention tools is a vital step toward reaching wholly preventative care. Dr. Oz can achieve a win for millions of Americans by confronting MACs head-on and protecting the coverage of diagnostic cancer testing. According to the National Cancer Institute, more than 2 million Americans were diagnosed with cancer in 2024. While a cure has yet to be found, we continue to see impressive breakthroughs in treatment every day.
Genetic testing is one such breakthrough. It allows doctors to find potential mutations or other changes in genes that could increase a patient’s risk for certain types of cancer. For those who have already been diagnosed, these tests help guide—and personalize—treatment plans, which may help patients avoid having to undergo more invasive interventions, such as chemotherapy or radiation therapy. For America’s seniors, access to these treatments hangs in the balance—and is becoming increasingly restricted.
Through a review process called a local coverage determination (LCD), MACs determine if a “particular item or service” should be covered under Medicare. This is supposed to be an unbiased, evidence-based process. But recent LCDs have called into question the MACs’ adherence to this process.
In 2023 Palmetto GBA, one of seven MACs nationwide, proposed limiting the coverage of blood tests for patients with organ transplants. After justified backlash, Palmetto GBA rescinded this guidance. The subsequent revelation that the MAC ignored expert recommendations justifiably raises questions about the intentions of these groups and their “unbiased” and “independent” status. Less than two years later, Novitas Solutions has finalized an LCD that prevents Medicare from covering a range of genetic tests used to help treat patients with cancer or those suspected of having cancer.
Experts have pointed out that not only do these decisions hurt patients but also that the process through which they are arrived at is extremely flawed. There has been little consistency as to what the MACs classify as “medically necessary.” Furthermore, they make hasty decisions about coverage, often without considering important medical evidence or the impact on patients. By deprioritizing preventative treatments such as genetic testing for cancer, MACs also drive up the cost of healthcare, leaving taxpayers to foot the bill.
Recent studies have also supported the fact that at least two of the tests impacted by Novitas’ LCD would actually lower the overall cost of care. A study evaluating a bladder cancer recurrence test that Novitas doesn’t want to cover found the test to be safe, patient-friendly and saved a health provider $39,000 over a three-year period.
Another study found that when doctors used a genetic test for skin cancer, they were able to better assess whether or not a patient needed adjuvant radiation therapy (ART). This test would not only prevent the unnecessary use of a highly risky and invasive treatment but also save taxpayers close to $1 billion dollars in annual costs.
President Trump, Congress and the Department of Government Efficiency are looking to reduce government spending and alleviate the burden on taxpayers. Clearly, effective precision medicine tests such as these are a clear avenue that should be pursued. Allowing this LCD to stand will remove patient access and burden many Americans physically and financially.
MACs are a cautionary example of the problems with socialized medicine and the consolidation of healthcare. In countries with a single-payer system, such as in Canada and the United Kingdom, patients are left with little to no choice in the type of healthcare they receive. Budgetary constraints allow government bureaucrats to decide who gets care and what care they receive. We can’t allow the U.S. to fall victim to these same systems. There are currently seven MACs presiding over the entire system, making decisions that impact our entire country.
It’s simple math: Poor decision-making plus unaccountable middlemen equals bad healthcare. At the mercy of MACs, seniors on Medicare continue to lose access to groundbreaking genetic tests that are essential to keeping them healthy as well as improving the quality of life for all.
There’s no reforming healthcare or “Making America Healthy Again” without reforming the MAC system. Dr. Oz must use the mandate given him by President Trump to hold MACs accountable and protect our country’s patients.