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Thinner benefits and coverage changes await many older Americans shopping for health insurance this fall. That’s if their plan is even still available in 2025.

More than a million people will probably have to find new coverage as major insurers cut costs and pull back from markets for Medicare Advantage plans, the privately run version of the federal government’s coverage program mostly for people ages 65 and older.

Industry experts also predict some price increases for Medicare prescription drug plans as required coverage improvements kick in.

Voters will learn about the insurance changes just weeks before they pick the next president and as Democrat Kamala Harris campaigns on promises to lower health care costs. Early voting has already started in some states.

“This could be bad news for Vice President Harris. If that premium is going up, that’s a very obvious sign that you’re paying more,” said Massey Whorley, an analyst for health care consulting company Avalere. “That has significant implications for how they’re viewing the performance of the current administration.”

Insurance agents say the distraction of the election adds another complication to an already challenging annual enrollment window that starts next month.

Insurers are pulling back from Medicare Advantage

Medicare Advantage plans will cover more than 35 million people next year, or around half of all people enrolled in Medicare, according to the federal government. Insurance agents say they expect more people than usual will have to find new coverage for 2025 because their insurer has either ended a plan or left their market.

The health insurer Humana expects more than half a million customers — about 10% of its total — to be affected as it pulls Medicare Advantage plans from places around the country. Many customers will be able to transfer to other Humana plans, but company leaders still anticipate losing a few hundred thousand customers.

CVS Health’s Aetna projects a similar loss, and other big insurers have said they are leaving several states.

Insurers say rising costs and care use, along with reimbursement cuts from the government, are forcing them to pull back.

Some people can expect a tough search

When insurers leave Medicare Advantage markets, they tend to stop selling plans that have lower quality ratings and those with a higher proportion of Black buyers, said Dr. Amal Trivedi, a Brown University public health researcher.

He noted that market exits can be particularly hard on people with several doctors and on patients with cognitive trouble like dementia.

Most markets will still have dozens of plan choices. But finding a new option involves understanding out-of-pocket costs for each choice, plus figuring out how physicians and regular prescriptions are covered.

“People don’t like change when it comes to health insurance because you don’t know what’s on the other side of the fence,” said Tricia Neuman, a Medicare expert at KFF, a nonprofit that researches health care.

Plans that don’t leave markets may raise deductibles and trim perks like cards used to pay for utilities or food.

Those proved popular in recent years as inflation rose, said Danielle Roberts, co-founder of the Fort Worth, Texas, insurance agency Boomer Benefits.

“It’s really difficult for a person on a fixed income to choose a health plan for the right reasons … when $900 on a flex card in free groceries sounds pretty good,” she said.

Don’t “sleep” on picking a Medicare plan

Prices also could rise for some so-called standalone Part D prescription drug plans, which people pair with traditional Medicare coverage. KFF says that population includes more than 13 million people.

The Centers for Medicare and Medicaid Services said Friday that premiums for these plans will decrease about 4% on average to $40 next year.

But brokers and agents say premiums can vary widely, and they still expect some increases. They also expect fewer plan choices and changes to formularies, or lists of covered drugs. Roberts said she has already seen premium hikes of $30 or more from some plans for next year.

Any price shift will hit a customer base known to switch plans for premium changes as small as $1, said Fran Soistman, CEO of the online insurance marketplace eHealth.

The changes come as a congressional-approved coverage overhaul takes hold. Most notably, out-of-pocket drug costs will be capped at $2,000 for those on Medicare, an effort championed by Democrats and President Joe Biden in 2022.

In the long run, these changes will lead to a “much richer benefit,” Whorley said.

KFF’s Neuman noted that the cap on drug costs will be especially helpful to cancer patients and others with expensive prescriptions. She estimates about 1.5 million people will benefit.

To ward off big premium spikes because of the changes, the Biden administration will pull billions of dollars from the Medicare trust fund to pay insurers to keep premium prices down, a move some Republicans have criticized. Insurers will not be allowed to raise premium prices beyond $35 next year.

People will be able to sign up for 2025 coverage between Oct. 15 and Dec. 7. Experts say all the potential changes make it important for shoppers to study closely any new choices or coverage they expect to renew.

“This is not a year to sleep on it, just re-enroll in the status quo,” said Whorley, the health care analyst.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.

NEW YORK (AP) — Our children are told when they’re little: Play nicely. Work together. Don’t hit. Use your words. Multiply that by nearly 200 countries, leaders of varied backgrounds and a preposterously complex set of 21st-century priorities and goals, and you come up with what exists in the world today: the United Nations.

There, the word for “play nicely” and “work together” is a complex one — “multilateralism” — and its goals often get lost in its syllables. But the principle remains the same: Unite to get more done, unite to offset bullies, unite to find outcomes that all can endorse and that benefit as many of the planet’s human beings as possible — and can be the foundation for an eventual lasting world peace.

At the U.N. General Assembly this week, it’s a principle that leaders — and, not surprisingly, leaders of smaller nations most of all — mention constantly. That’s not just because the U.N. has stood for multilateralism since it rose from the dictator-inflicted rubble of World War II. It is because today, in an interconnected era where human fates lie more than ever in what other humans do in other places, cooperation isn’t just an ideal but a necessary reality, whether anyone wants it or not.

But the problem, many leaders say, is that despite that hope that the U.N. still offers, the aging model of multilateralism — “a mirror that obstinately reflects the values of 1945,” according to Mexican Foreign Minister Alicia Bárcena — hasn’t been retooled to be effective in an era it quite possibly never envisioned.

“We cannot ignore that our common multilateral progress is failing us in the hour of greatest need,” said Hilda Heine, president of the Marshall Islands.

“This old political shell of the post-1945 political order can barely contain the contradictions,” said Ralph Gonsalves, the prime minister of Saint Vincent and the Grenadines. “We cannot continue to rule in the old way, but the new is yet to be born.”

The old model isn’t working anymore

Both of those nations are small ones, and that’s no coincidence. Though many larger nations embraced multilateralism and still do — to a point, depending on their own strategic priorities — it is smaller states that embrace it most fervently. After all, they stand to benefit most from a united front in everything from military operations to development. “For small states, multilateralism in international law is not an option. It is in fact an existential necessity,” Singapore’s foreign minister, Vivian Balakrishnan, said Saturday.

Four generations after World War II ended, the challenges of the 21st century and — of late — the rising tide of populism have led many to conclude that old models of multilateralism aren’t working. But even leaders who still believe that working together and equally is ultimately the most effective and most secure way to do things lamented, one after another, that they are still waiting for the emergence of such a fresh approach.

António Guterres, head of the United Nations for the past seven years, has spent most of that time preaching passionately about the virtues of multilateralism — first patiently, then less so, then more urgently, now increasingly desperately. He knows things aren’t working. He believes they still can — not in spite of an increasingly complex world but precisely because of its realities.

“I have no illusions about the obstacles to reform of the multilateral system,” Guterres told leaders this week. “Those with political and economic power – and those who believe they have power – are always reluctant to change. But the status quo is already draining their power. Without reform, fragmentation is inevitable, and global institutions will become less legitimate, less credible and less effective.”

Fragmentation. That’s a key word here. The rise of the internet and the global economy and the subsequent repercussions stitched things together in some ways but tore them into a million pieces in others. Long-prevailing narratives are crumbling — for good and for ill. Putting the pieces back into a recognizable and productive mosaic — the very job of the United Nations — is a Sisyphean task.

This is where most conversations about multilateralism tend to end up. The very things that make it strong — many voices, many backgrounds, many diverse priorities — also make it, and the United Nations itself, almost impossible to wrangle.

That has a particularly strong impact on those smaller states, which need that collaboration desperately in the face of larger, more muscular ones.

Increasingly beleaguered Tuvalu can’t solve the encroaching waters of climate change on its own. Saint Kitts and Nevis isn’t going to figure out all the impact of AI alone. Without a thriving international economy, there are a lot more problems that descend upon everywhere from Kazakhstan to Suriname to Eswatini. African nations in particular have been seeking a permanent seat on the powerful U.N. Security Council so they can have a strong bloc of cooperation — and power — within the larger one.

“Multilateral institutions, including the Security Council, do not represent African needs and aspirations,” said Nangolo Mbumba, Namibia’s president.

New approaches — and fast — are seen as pivotal

Because of the wide perception that multilateralism is at a breaking point, Guterres this year convened a summit that produced a “Pact for the Future,” a wide-ranging plan that the secretary-general said was “designed to bring multilateralism back from the brink.”

He said that, unlike many other U.N. initiatives, this one must be more than talk and documents but produce tangible, collaborative results in coming years. Essentially, it resembles a soft reboot of the United Nations itself to make it more relevant in an age of globalization, interconnectivity, fragmentation and artificial intelligence.

Many speakers this week have seized upon precisely that kind of modernization across the board — what Mohamed Irfaan Ali, the president of Guyana, called “enlightened multilateralism.” To nations like his, that notion would represent a more substantive inclusion, a world in which they are not simply partners but equal partners — not just being a member of the club of nations, but helping to run the clubhouse.

Could the “great powers” ever accept this? Could a reset, even a limited one, of the only truly global body of nations push the United Nations back on the path it has long envisioned? Everyone, including Guterres, insists that it’s possible — but that time for a new and reinvigorated multilateralism is running out.

“The world stands fractious, polarized and frustrated. Conversations have become difficult; agreements even more so,” said Indian Foreign Minister Subrahmanyam Jaishankar. “Conversations have become difficult, agreements even more so. This is surely not what the founders of the U.N. would have wanted of us.”

The founders recognized that people wouldn’t always play nicely — but that they had to work together. And, ideally, not hit each other. And using their words? Even in a forum committed to dialogue and understanding (not to mention long equipped with real-time translation), that is becoming a taller order with each passing year. “If we carry on like this,” Jaishankar said Saturday, “the state of the world is only going to get worse.”

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Ted Anthony, director of new storytelling and newsroom innovation for The Associated Press, has been writing about international affairs since 1995. Follow him at

PRAIRIE DU CHIEN, Wis. (AP) — Former President Donald Trump meandered Saturday through a list of grievances against Vice President Kamala Harris and other issues during an event intended to link his Democratic opponent to illegal border crossings.

A day after Harris discussed immigration at the U.S.-Mexico border, Trump spoke to a crowd in Prairie du Chien, Wisconsin, about immigration. He blamed Harris for migrants committing crimes after entering the U.S. illegally, alleging she was responsible for “erasing our border.”

“I will liberate Wisconsin from the mass migrant invasion,” he said. “We’re going to liberate the country.”

Trump hopes frustration over illegal immigration will translate to votes in Wisconsin and other crucial swing states. The Republican nominee has denounced people who cross the U.S.-Mexico border as “poisoning the blood of the country” and vowed to stage the largest deportation operation in American history if elected. And polls show Americans believe Trump would do a better job than Harris on handling immigration.

Trump shifted from topic to topic so quickly that it was hard to keep track of what he meant at times. He talked about the two assassination attempts against him and blamed the U.S. Secret Service for not being able to hold a large outdoor rally instead of an event in a smaller indoor space. But he also offered asides about climate change, Harris’ father, how his beach body was better than President Joe Biden’s, and a fly that was buzzing near him.

“I wonder where the fly came from,” he said. “Two years ago, I wouldn’t have had a fly up here. You’re changing rapidly. But we can’t take it any longer. We can’t take it any longer.”

Trump repeatedly brought up Harris’ Friday event in Douglas, Arizona, where she announced a push to further restrict asylum claims beyond Biden’s executive order announced earlier this year. Harris denounced Trump’s handling of the border while president and his opposing a bipartisan border package earlier this year, saying Trump “prefers to run on a problem instead of fixing a problem.”

“I had to sit there and listen” to Harris last night Trump said, eliciting cheers. “And who puts it on? Fox News. They should not be allowed to put it on. It’s all lies. Everything she says is lies.”

The Republican nominee also intensified his personal attacks against Harris, insulting her as “mentally impaired” and a “disaster.”

Trump professed not to understand what Harris meant when she said he was responsible for taking children from their parents. Under his administration, border agents separated children from their parents at the U.S.-Mexico border in a policy that was condemned globally as inhumane and one that Trump himself ended under pressure from his own party.

On either side of the stage with Trump were poster-sized mug shots of men in the U.S. illegally accused of a crime, including Alejandro Jose Coronel Zarate, a case Trump cited in his speech.

Wisconsin Republicans in recent days have cited the story of Coronel Zarate’s arrest in Prairie du Chien as more evidence that people in the country illegally are committing crimes across the United States, not just in southern border states. Prosecutors charged Coronel Zarate on Sept. 18 with sexual assault, child abuse, strangulation and domestic abuse. His lawyers declined to comment.

Police Chief Kyle Teynor posted statements on Facebook saying that Coronel Zarate is not a U.S. citizen and that he had two fake immigration documents, including a fake Social Security card. The chief added that Coronel Zarate’s tattoos indicate he’s affiliated with the Tren de Aragua gang, which started in Venezuelan prisons and is posing a growing threat in the U.S.

Speaking to the crowd Saturday, Teynor stressed to the crowd that Coronel Zarate is the only Venezuelan gang member his agency has encountered, but the violence his two alleged victims suffered at his hands earlier this month was very real.

Republicans including U.S. Sen. Derrick Van Orden, who is from Prairie du Chien, have criticized authorities in both Minneapolis and Madison for letting Coronel Zarate go, saying they essentially allowed him to attack the woman in Prairie du Chien. They have accused both jurisdictions of being sanctuaries for people in the country illegally.

Van Orden told the crowd Trump was the only one who could restore order.

“You’re going to see the one man who has enough strength and courage of conviction to stand up to anyone up to and including being shot in the head for us,” he said.

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Long reported from Washington.

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