Letters from An American, February 18, 2024, by Heather Cox Richardson

---

That the American people in the twenty-first century celebrate Abraham Lincoln as a great president would likely have surprised Lincoln in summer 1864, when every sign suggested he would not be reelected and would go down in history as the man who had permitted a rebellion to dismember the United States.

The news from the battlefields in 1864 was grim. …  As the casualties mounted, so did criticism of Lincoln. …

[Lincoln wrote:] “… it seems exceedingly probable that this Administration will not be re-elected. …”

But then his fortunes turned.

… the Democrats chose as a presidential candidate General George McClellan … [and] rejected the new, popular measures the national government had undertaken since 1861—the establishment of state colleges, the transcontinental railroad, the new national money, and the Homestead Act—insisting on “State rights.”

Americans who had poured their lives and fortunes into the war and liked the new government were not willing to abandon both to return to the conditions of three years before.

Lincoln won about 55% of the popular vote compared to McClellan’s 45%, and 212 electoral votes to McClellan’s 12.

---

ChatGPT-4, February 19, 2024, Query by JGK: What is the role of presidents in health reform?

---

The role of presidents in health insurance reform in the United States has been significant, as they often serve as the primary advocates for major policy changes and help set legislative agendas. Here’s an overview of how U.S. presidents have influenced health insurance reform:

Vision and Agenda Setting: Presidents often use their platform to highlight the need for health insurance reform, setting the vision and goals for what they hope to achieve. This can include expanding coverage, reducing costs, improving the quality of care, or a combination of these objectives.

Legislative Leadership: Presidents work closely with Congress to draft and promote health insurance reform legislation. They may propose specific bills or outline key principles that they want the legislation to address. Through negotiations and collaborations with lawmakers, presidents can guide the legislative process.

Public Advocacy: Presidents engage in public advocacy to garner support for health insurance reform. This can involve speeches, press conferences, and public appearances. Effective communication can help rally public support, which in turn can influence legislators.

Political Capital: Presidents often expend significant political capital to push through health insurance reforms. This can be risky, as unsuccessful reform efforts or unpopular policies can impact a president’s approval ratings and influence over other policy areas.

Executive Actions: When legislative efforts stall, presidents may use executive actions to implement certain health insurance reforms. While these actions are generally more limited in scope compared to comprehensive legislation, they can still have a significant impact on the health insurance landscape.

Collaboration with Stakeholders: Presidents and their administrations engage with various stakeholders, including insurance companies, healthcare providers, patient advocacy groups, and the business community, to build consensus and address concerns related to proposed reforms.

Historical Examples:

• Harry S. Truman: Failed in attempt to enact national health insurance.
• Lyndon B. Johnson: Enacted Social Security Amendments of 1965, creating Medicare and Medicaid, for elderly, long-term disabled, and low-income individuals.
• Bill Clinton: After failed comprehensive reform, implemented the State Children’s Health Insurance Program.
• George W. Bush: Expanded Medicare to include prescription drugs.
• Barack Obama: Enacted the Affordable Care Act (ACA).
• Donald Trump: Failed to repeal the ACA; implemented rules to undermine parts of it.
• Joe Biden: Temporarily increased ACA premium supports and extended Medicaid enrollment, as part of COVID response. Enacted Medicare drug beneficiary spending caps and some price negotiations.

---

Comment:

By Jim Kahn, M.D., M.P.H.

Lincoln’s moral vision and practical political skills saved the union and freed the slaves. Toward the end of his first term, the war was going poorly, and he faced dismal re-election prospects. Then, his opponent’s rejection of fundamental reforms intended to strengthen the nation and give a hand up to the less fortunate – along with key military victories – turned the tide to resounding victory at the polls. He was soon assassinated, undermining his legacy, and the nation suffered decades of disruption as the South resisted equality for the freed slaves. Yet his shining moral example and accomplishments reverberate more than 150 years later.

Each major health reform is properly associated with the president under whom it occurred — reflecting their vision of the needed and possible. Of course, presidential affiliation with a particular reform doesn’t tell the full story – of the perceived needs for change, a sense of the possible, advocacy by interest groups, and Congressional deal-making.

All the presidents have fallen short of the ultimate solution – universal comprehensive benefits through a greatly simplified financing system. Some tried (e.g., Truman and in a different form, Nixon); some aimed low (e.g., GW Bush); and some combined ambitiousness with perpetuation of the current flawed structure (e.g., Clinton and Obama).

In my view, there is only one reasonable way forward: the globally tried and true uniform insurance for all. In the US, that’s single payer. If we want to start with a few states to test and refine, that’s ok.

Many will say, it’s not politically possible. To which I respond that in Lincoln’s time many didn’t think it was possible to preserve the union and free the slaves, and in Washington’s time most assumed he would retain power indefinitely – but he stepped down.

The most morally visionary presidents take the US in great directions. A president who brings us universal comprehensive health insurance will become as hallowed as the two leaders we most celebrate today.

https://healthjusticemonitor.org…

---

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Is the No Surprises Act backfiring on patients? And why is HHS Secretary Becerra letting it happen?, Health Care Un-Covered, February 14, 2024, by Wendell Potter

---

[O]ne area of real compromise, and policy achievement, in recent years came in December 2020 with the passage of the No Surprises Act (NSA).

For a decade, patients had seen an increase in “surprise bills” that were generated after an emergency room visit or some hospital-based procedures. In many cases, after a doctor provided emergency or specialist care at a hospital to a patient whose insurance was not “in-network” with that doctor, the patient received a bill for the balance left unpaid by their insurer. Sometimes those bills were into the tens and hundreds of thousands of dollars, driving a surge in medical debt.

The NSA took two years of intense deliberation by Congress and resulted in a significant bipartisan achievement for patients. It credibly addressed the problem in a way that was a compromise for insurers and doctors. It created a mechanism to set a reasonable, market-based rate for out-of-network medical procedures. As enacted by Congress, it seemed to be a fair means of resolving payment disputes between doctors and insurers, without patients in the middle. Consumers stopped receiving surprise bills and–even I believed–this was the rare problem in our health system that had been resolved fairly.

I was wrong. And to my surprise, the fault lies squarely at the feet of the Biden administration’s Department of Health and Human Services (HHS). The way the administration wrote the regulations, undoubtedly with “help” from my former colleagues, insurers scored a major advantage. In doing so a law that was meant to be a shield for patients has turned into a sword for insurers.

Since the act’s implementation in 2022, HEALTH CARE Un-covered has learned, in talking with doctors around the country, that insurers have abused their authority under the law. This gets technical, so bear with me.

The law created a new way to set the average cost of specific care in specific markets – called Qualified Payment Amounts (QPAs) – that is supposed to be the basis of patient cost-sharing. It’s also one of the factors in an arbitration process set up in the law when payers and providers can’t agree on out-of-network payment.

The problem is that the Biden Administration’s regulations empowered insurers to set the QPA amount and then made it a “rebuttable presumption” of payment in the arbitration–meaning the QPA as determined by the insurer is just assumed to be appropriate and fair–ignoring all other factors. … insurers have become the foxes guarding the hen house. …

Insurers are using the law to slash payments to doctors to boost profits.

[O]ver the past two years, the law has empowered insurers to terminate contracts and offer far lower payment rates in return. Here’s how it works: an insurer tells a group of emergency room doctors they will no longer pay $100 for a procedure. Instead, the insurer says it will pay $40. Outraged, the doctors decline, which triggers the arbitration rules set out under the NSA.

[Then, the QPA specified by insurers strongly tilts the arbitration their way.] …

There is a mechanism in the law to ensure this doesn’t happen, and insurers have to provide a reasonable QPA to the arbiter, and the QPA is supposed to only be one of several factors considered as to what rate is reasonable. And that, unfortunately, is where the failure of HHS Secretary Xavier Becerra is laid bare. Despite multiple federal court rulings against insurers and in favor of hospital-based doctors, Becerra’s agency has refused to enforce the act to ensure fair payment rates to both sides.

Now, you might be thinking, why should I care? …

[T]here has been a worsening shortage of doctors in rural and underserved areas. Emergency room wait times are increasing, and specialists are becoming more difficult to schedule. The NSA, as written by Congress, would have stopped surprise billing by bad actors while stabilizing the health care system by creating an equal playing field for resolving out-of-network disputes between insurers and providers. …

Why did CMS feel the need to give insurers a pass on this critical piece of legislation?  Well, in its recent guidance, CMS was concerned that insurers would have “significant challenges associated with the recalculations” of the QPA and that it would “require significant resources and take many months if not longer.”  This comment has been met with utter disbelief from hospitals and doctors who are struggling with significant challenges …

As insurers are using HHS’ approach to enforcement to squeeze providers to drive higher profits, the casualty is ultimately the patient. Becerra has been hounded by Republicans and Democrats alike on this issue, and he should take notice. Not enforcing a bipartisan law as Congress intended to the benefit of insurers is policy–and political–malpractice. And it affects a core constituency of President Biden’s: working Americans with employer-based insurance who deeply value the benefits they believe they have.

---

Comment:

By Jim Kahn, M.D., M.P.H.

The terrific post by Wendell Potter discusses a perfect example of “regulatory capture.” That is, the entities being regulated (the insurers) influence regulation rules and processes to their considerable advantage. What looks like a benign term or phrase yields out-sized benefits. Huge impact cloaked in technical minutia.

Wendell attributes this situation to Secretary Becerra* and the likely influence of insurance lobbyists. I don’t disagree. However, the “revolving door” of employment in DHHS and its insurance regulator CMS (Center for Medicare and Medicaid Services) means that regulation writers may have a mindset and incentive to lean toward insurers. On many issues (if not this one), Congress exerts a pro-insurer influence.

Other recent examples of regulatory capture covered in HJM include:

1. Multiple technical tweaks that generate Medicare Advantage over-payments of >$100 billion per year.
2. A delay in / lowering of proposed corrections to risk adjustment gaming, worth $10 billion to insurers for 2024.
3. A requirement in ACO REACH to pay participating physicians lower than regular Medicare rates … saving the corporate intermediaries money and co-opting physicians into being co-conspirators for suppressing care utilization by patients.

So, the Biden administration is complicit with health insurers. This is not news, indeed the Affordable Care Act (Biden’s “big f-ing deal”) is a massive gift to insurers.

But make no mistake, the situation would be massively worse under a second Trump administration. We saw in his first (we hope only) term that ACA rules assuring fair insurance policies were completely circumvented by changing the definition of “temporary policy” to anything 364 days or less.

Let’s hold the HHS/CMS regulatory feet to the fire. But also, let’s give the Biden administration, despite blemishes in the health care arena, a chance to burnish its record.

By the way … as you know … under single payer, “out-of-network” charges is a non-issue.

* In his prior California role, Becerra was a single payer supporter.

https://healthjusticemonitor.org…

---

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

A Call To Action To Take The Profession Back from Corporate Interests, TAKE MEDICINE BACK, October 2023, by Mitchell Li, M.D.; Sailesh Konda; and Robert McNamara

---

Conclusion:

The corporate practice of medicine doctrine was integral in providing an ethical basis for the practice of medicine. Today, the AMA explicitly tolerates the corporate practice of medicine, and state prohibitions on CPOM are broadly unenforced. The vast majority of physicians are now employees of increasingly consolidated corporations, while moral injury and burnout among physicians are at unsustainable levels. Rapid horizontal and vertical consolidation of non-physician healthcare corporations that employ physicians not only increases monopoly power over consumers, which in return increases costs, but also increases monopsony power over physician labor. This has resulted in anti-competitive labor practices that lead to intimidation of, and retaliation against physicians who advocate for patients. This places the public at risk through greater corporate influence over the practice of medicine. …

A new era of robust antitrust enforcement in healthcare is needed. Past FTC actions against the AMA restricting the ability to impose ethical restrictions on its members should be re-examined in the context of unintended consequences of enabling corporatization and consolidation. A national prohibition on the corporate practice of medicine is necessary to accompany the strengthening, and enforcement of existing state-based prohibitions. Physician organizations must collectively reject non-physician corporate ownership of medical practices. Reclaiming the profession from corporate interests will take time, and greater protections for employed physicians are needed now in order to protect patients. In the face of legislative inaction at the state and federal level, employed physicians should use the tools available to labor and organize through unionization.

[HJM bolding]

---

The Corporate Practice of Medicine By The Numbers

---

• 74% – Physicians employed by corporate entities
• 34 – States prohibit the corporate practice of medicine to protect patients – and enforced in none of them
• 87% – Of physicians say patients trust them less than they did a decade earlier
• 140 million – Americans facing financial hardship due to healthcare bills
• $1 Trillion – Worth of private equity transactions in healthcare over the past decade
• 63%  – Of physicians reporting burnout in 2020 – an all-time high, and rising
• 2.51 – Replacement ratio of physicians by non-physician practitioners in private-equity owned medical practices
• 1 in 4 – U.S. Medical Students are considering quitting their studies
• 58% – of U.S. Medical and Nursing students do not intend to treat patients
• 1 in 10 – physicians working under or for United Health

---

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D, M.P.H.

In 1980, NEJM editor Arnold Relman, M.D. issued the warning of the relatively unheralded rise of a huge new industry that supplies health-care services for profit which he labeled the “medical-industrial complex.” He concluded, “How best to ensure that the medical-industrial complex serves the interests of patients first and of its stockholders second will have to be the responsibility of the medical profession and an informed public.”

Apparently the medical profession and the public have largely failed in this responsibility – based on the statistics showing that private ownership and profits are shifting to private equity, yielding dissatisfaction of both health care professionals and, most importantly, patients.

Today’s HJM directs our attention to an organization that is sounding a call to action to “take the profession back from corporate interests.” The name of their organization is simply TAKE MEDICINE BACK. They have produced a very easy-to-read 63-page paper. Their recommendations are complementary to those of Physicians for a National Health Program and other organizations that support health care justice for all.

We should work together to take medicine back from private equity and the corporate world and use it to fulfill our dreams of realizing comprehensive, equitable, affordable, high quality care for absolutely everyone. Those of us who really care are now busy aligning ourselves in the direction that will get us there. Let’s go!

https://healthjusticemonitor.org…

---

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Opinion: Ouch. That ‘free’ annual checkup might cost you. Here’s why, Washington Post, January 24, 2024, by Elisabeth Rosenthal

---

When Kristy Uddin, 49, went in for her annual mammogram in Washington state last year, she assumed she would not incur a bill because the test is one of the many preventive measures guaranteed to be free to patients under the 2010 Affordable Care Act. The ACA’s provision made medical and economic sense, encouraging Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.

So when a bill for $236 arrived, Uddin — an occupational therapist familiar with the health-care industry’s workings — complained to her insurer and the hospital. …

The ACA’s designers might have assumed that they had spelled out with sufficient clarity that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies and recommended vaccines, in addition to doctor visits to screen for disease. But the law’s authors didn’t reckon with America’s ever-creative medical billing juggernaut. …

[HJM: see the article for more examples of this “billing minefield”. And see also
The colonoscopies were free but the ‘surgical trays’ came with $600 price tags]

---

Republicans Are Planning to Totally Privatize Medicare — And Fast, Rolling Stone, February 5, 2024, by Andrew Perez

---

The right-wing policy agenda written for a new Donald Trump presidency would “greatly accelerate” efforts to privatize Medicare.

Last year, for the first time ever, a majority of Americans eligible for Medicare were on privatized Medicare Advantage plans. If Republicans win the presidential race this year, the push to fully privatize Medicare, the government health insurance program for seniors and people with disabilities, will only intensify.

Conservative operatives have already sketched out what the GOP’s policy agenda would look like in the early days of a new Donald Trump presidency. As Rolling Stone has detailed, the proposed Project 2025 agenda is radically right-wing. One item buried in the 887-page blueprint has attracted little attention thus far, but would have a monumental impact on the health of America’s seniors and the future of one of America’s most popular social programs: a call to “make Medicare Advantage the default enrollment option” for people who are newly eligible for Medicare.

Such a policy would hasten the end of the traditional Medicare program, as well as its foundational premise: that seniors can go to any doctor or provider they choose. The change would be a boon for private health insurers — which generate massive profits and growing portions of their revenues from Medicare Advantage plans — and further consolidate corporate control over the United States health care system.

---

Comment:

By Jim Kahn, M.D., M.P.H.

We know very well that the fundamental purpose of the private health insurance business is to make money for shareholders. HJM has highlighted the massive profits which are enhanced by high financial barriers to care and tens of billions of dollars in overcharges to public payers like Medicare.

Now we learn of two more startling examples of shady business tactics, present day and dystopian future.

1) Creative billing. A mandated benefit of the Affordable Care Act is free-to-the-patient preventive care. That is, insurers pay fully. But sometimes they don’t. It turns out that segmenting prevention services into pieces, or piling on non-prevention services, hits patients with hundreds of dollars in fees. Not free! Reminds me of the massive “convenience,” “processing,” and “delivery” fees imposed when renting or purchasing a car, buying concert tickets, or banking. Idiosyncratic provider billing confuses matters. But insurers have an incentive to be negligent – if they fail to assure that charges are appropriately bundled in a prevention package, it lowers their costs as some costs land with patients.

2) “Default Enrollment to Medicare Advantage”. This scheme is in the dystopian Project 2025 laid out by the MAGA GOP – a 920-page blueprint for far-right policy implementation if Trump wins in 2024. Buried deep in the text is the idea that the choice of traditional Medicare vs. Medicare Advantage should “default” to the latter. That is, unless new Medicare beneficiaries “opt out” of MA, they’re stuck with it, and with the MA problems (like financial barriers and narrow networks) which we’ve written about. How much does this matter? A lot – one academic review estimated a 27% shift, e.g., from 40% MA to 67% MA. The exact effect will depend on wording, and could be a lot more. This is “behavioral economics” – e.g., nudging actions through choice framing, wording, or visual layout. If in the interest of helping people (e.g., eat healthier), terrific. If in the interest of building profits for shareholders with public money, terrible.

We need a single, government payer. It will end complex billing rules and manipulations to increase insurer profits. It will turn health insurance into a public good optimizing public benefit.

https://healthjusticemonitor.org…

---

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Federal Budgetary Effects of the Activities of the Center for Medicare & Medicaid Innovation, U.S. Congressional Budget Office, September 2023

---

The Center for Medicare & Medicaid Innovation (CMMI) was created by the Affordable Care Act (ACA) in 2010. It conducts pilot programs, known as models, that test new ways to deliver and pay for health care in Medicare, Medicaid, and the Children’s Health Insurance Program, with the goal of identifying approaches that reduce spending or improve the quality of care.

CBO currently estimates that CMMI’s activities increased direct spending by $5.4 billion … between 2011 and 2020. …

By contrast, in 2010, when the ACA was enacted, CBO projected that CMMI would produce net savings over the 2010–2019 period. …

Looking ahead, CBO currently projects that CMMI’s activities will increase net federal spending by $1.3 billion, or 0.01 percent of net spending on Medicare … from 2021 to 2030.

---

The CBO Report That Didn’t Roar, KFF, January 4, 2024, by Drew Altman (KFF CEO & President)

---

A Congressional Budget Office (CBO) report in September slipped … largely unnoticed by the larger health community despite its potentially broad implications for efforts to promote value through popular payment changes. …

CBO found that most of post Affordable Care Act (ACA) payment and delivery demonstrations launched by the Centers for Medicare and Medicaid Innovation (CMMI) in CMS between 2011 and 2020 did not save money as intended, and cost the government $5.4 billion more than they saved, including administrative costs associated with them. CBO also projected that CMMI would be a net loser cost-wise for Medicare through 2030.

This matters because the CMMI demonstrations have been widely regarded as the leading edge of a generation of value-based payment initiatives which have become the primary cost strategy in the U.S. over the past decade, displacing what had always been the dominant schools of cost containment, competition (favored by conservatives), and regulation (favored by liberals). …

CMS’s goal remains to see every Medicare beneficiary in some form of accountable care arrangement in seven years. And recently former Health and Human Services Secretary Alex Azar called for an end to demos altogether, feeling value-based payment was the way to go. After all, Medicare spending growth has slowed in recent years. While the full explanation for that is not well understood, it’s possible that the drive towards value-based payment and accountable care has changed provider attitudes and behavior and is part of the explanation, though that is difficult to quantify. Still, Medicare spending is expected to accelerate in the future.

Back to the CBO report. Whatever the results of a particular group of demonstration projects, CMS will always need the authority to experiment with changes in its three big programs: Medicare, Medicaid, and the ACA. In a more perfect world not every demonstration would need to save the federal government money; some good things could actually cost more and might be worth investing in; for example, if they demonstrably improve access or health outcomes.

Having worked in CMS earlier in my career trying to coordinate waivers from the administrator’s office, and once been nominated to run the agency, I know the need to have a division within CMS, like CMMI, to oversee R&D activity. In fact, it would make good sense to better consolidate CMS waiver and demonstration activity across Medicaid, Medicare, and the ACA within the agency, but that’s truly inside baseball and a subject for another day.

---

Comment:

By Ana Malinow, M.D. and Jim Kahn, M.D., M.P.H.

The recent post by Drew Altman in “KFF Beyond the Data” spotlighted the overlooked but important Congressional Budget Office (CBO) report published in September on the budgetary effects of the Center for Medicare and Medicaid Innovation (CMMI). The report strikingly found that in its first decade, the CMMI did not reduce Medicare program expenditures, as mandated and promised, but instead cost Medicare $5.4 billion more than it saved, with ongoing losses projected through 2023.

Instead of advocating that CMS / CMMI abandon its model of using value-based care to try to fix fee-for-service, Dr. Altman makes excuses as to why only six of the 49 demonstration models produced modest savings. It goes further, wishing “equity” into existence if CMMI just integrates a “focus on equity on everything [it] does.” The evidence available suggests that VBC fails to control costs [i], improve quality, or increase equity. Defining and measuring value is extremely difficult, and as a result, CMMI pilots have little to do with value and lots more to do with cost (which, again, go up). We never have the data we need — complete, accurate, and timely. Little data, little value.

We all agree that CMS resources should be used efficiently to pay for care for enrollees. And we agree that CMS has not succeeded in that mission.

Where we disagree is what comes next. Dr. Altman supports continued experimentation with VBC. We believe that we now have ample evidence from the US and other countries that the fundamental problem is a health care system with a huge role for for-profit insurers and contracting intermediaries.

Can we (and especially Dr. Altman) say … our system is broken, resistant to real change with weak tools like value-based care, where financial incentives are primary and at odds with good care. CMS and the rest of us should follow the lead of dozens of other wealthy nations with identical comprehensive publicly mandated insurance for everyone, with no role for profit-oriented intermediaries. Time for single payer.

This represents an attack on the current system. Having someone like Dr. Altman, with his policy heft, making the argument would be revolutionary.

Can we move beyond what has failed and focus instead on improving and expanding Medicare?

---

[i] As discussed in the article’s comment, an updated analysis shows that MSSP further increases costs to Medicare. We’ll report on this soon.

https://healthjusticemonitor.org…

---

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.