Summary: Dr. Glaucomflecken and John Stewart offer a master class on how to concisely convey what’s wrong with US health insurance and why. A dozen 2-minute videos.

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Dr. Glaucomflecken, 30 Days of US Healthcare, September 2023, videos (2 min each)

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Job Benefits

Deductibles
Co-insurance
Surprise Billing
Pharmacy Benefit Managers
Insurance Kickbacks [to PBMs]
DIR Fees [PBM fees on pharmacies]
Out of Pocket Maximum

Hospital Price Transparency
Payment Processing Fees
Family Medicine Negotiates with UHC

And … An American Gets Health Care Abroad [2022]

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Medicare and Corporate Lobbyists in Congress [600 lobbyists: no drug price negotiations part D], The Problem With Jon Stewart, August 30, 2023

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Comment:

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

Health policy discussion is often laden with technical jargon. Dr. Glaucomflecken’s amusing skits (in which he plays all roles), and John Stewart’s interviews provide an excellent antidote – they distill fundamentals into biting 2-minute snippets.

Here’s a quick tour of the story they tell, progressing through the videos …

1) Problems with current insurance.

The health insurance “job benefit” actually lowers salary (the worker is paying!). The insurance seems barely worth it … First comes the deductible … thousands of dollars before coverage kicks in. Followed by co-insurance and surprise billing (incompletely resolved with recent legislation, eg ambulances omitted). Pharmacy benefit managers (owned by insurers) manipulate the drug formulary and payment process to extract profits, including dropping generic drugs in favor of brand name (and overcharging for generics). Finally, you hit the out-of-pocket maximum – but beware non-network and excluded services. No wonder medical debt is sky high.

Hospital price transparency is a farce: ignored and incomprehensible for consumers. Electronic billing (efficient, right?) is an excuse to impose a 5% processing fee on providers.

And, the insurers are buying up the doctors.

2) There’s a better way abroad.

In all other wealthy nations, everyone is covered with little or no cost-sharing. Pick your phrase: not rocket science, known technology, best practices.

3) Why, then?

Because, as Stewart says, health industry lobbyists and the donors who hire them control Congress. See the PBM video too – if you earn enough money, you make the laws. Is the Inflation Reduction Act, which the drug companies so hate, a harbinger of real reform?

It’s time for the people to dismantle the fragmented and dysfunctional system in favor of a simple approach that works for patients – single payer.

http://healthjusticemonitor.org…

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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.

Summary: Private for-profit ownership of health care is undermining the health care mission, diverting care resources to shareholder bank accounts. Single payer financing is not enough … we need to resist the corporate takeover. Two important webinars are coming up NEXT WEEK. Listen in, and get involved.

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Medicare for All Is Not Enough, The Nation, March 31, 2022, by David U. Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, and John Geyman; covered in HJM here

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Dr. Glaucomflecken videos (2 min each):

• 30 Days of US Healthcare: United Healthcare For All, September 20, 2023
• 30 Days of US Healthcare: Private Equity Visits Rural Medicine, September 19, 2023
• 30 Days of US Healthcare: Physician Owned Hospitals, September 9, 2023

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Comment:

By Don McCanne, M.D.

Single payer financing meets the goal of insuring everyone, funded equitably through progressive taxation. However, it is incapable of controlling the dictates of private ownership with a primary mission of increasing private wealth as opposed to providing the public service of health care for all. Private equity is acquiring not only facilities but also the health care professional groups staffing these facilities. Our article in The Nation summarizes these terrible trends, and Dr. Glaucomflecken distills the problems with his astringent humor. The public service model of single payer cannot work in a system designed to pump up the coffers of billionaires.

Two zoom webinars NEXT WEEK address the hazards of private ownership in health care:

1) The Lancet Webinars: Public policy and health in the USA miniseries: should investors own healthcare?

Tuesday September 26, 2023 2 pm EDT / 11 am PDT
Register here

Four US experts will examine the implications of growing investor ownership of physicians’ practices, hospitals, and other health services in the US, and their consolidation into giant corporate enterprises that dominate insurance and care delivery in many regions of the US. Panelists are luminaries Don Berwick, Rosemary Batt, Steffie Woolhandler, and Claudia Fegan.

2) Health Affairs:  Briefing: How the Ownership and Structure of Health Care Entities Affect Clinicians & Patients

Wednesday September 27, 2023 2 pm EDT / 11 am PDT
Register here

WATCH THE ZOOM MEETINGS AND THEN WORK TOGETHER TO FIGHT THIS PROCESS. WE HAVE TO DO IT. SINGLE PAYER WILL GO NOWHERE IF WE DO NOT ADDRESS THE OWNERSHIP HARM CAUSED BY THE BILLIONAIRES. WE HAVE TO REBUILD THE SYSTEM!

In solidarity and with love,

Don

http://healthjusticemonitor.org…

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Summary: Jon Stewart nails it in a vivid one-minute video: Our government-funded health care benefits private for-profit corporations, especially insurers, at our expense.

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America’s F*cked Up Tax System, The Problem With Jon Stewart, August 29, 2023, Video (1 min)

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Here’s how the system works. You pay taxes to the government, the government pools that money and uses it to provide the people with essential goods and services that they need.

In this country, we’ve got a different system for getting the things we need.

Take health care. We pay taxes to the government and the government gives our money to a middleman: for-profit insurance companies or for-profit health providers. And the insurance companies provide health coverage in exchange for maybe some more money for us and a deductible, that covers not everything certainly not your teeth or your skin or your eyes. It’s a pretty good system if you own an insurance company. Companies like UnitedHealth and Aetna collect 70% of their health plan revenue from government programs. Humana – 90%. These health plan businesses would not exist without our tax money. And it’s not just health care. It’s pharma. …

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Comment:

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

What a pleasure to have this talented comedian-social commentator-activist on our side. Jon Stewart is a hero of mine.

The irresistible implication? We need single payer, government-financed and government-paid universal health insurance. Without profit extraction by private sector intermediaries. It’s systematized grift, and we need to end it.

http://healthjusticemonitor.org…

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Summary: A new book by mainstream health economists and policymakers argues that we should expand and tinker with Medicare Advantage to save Medicare. But why double down on the part of Medicare that is extracting massive profits and limiting access to care?

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A New Prescription For What Ails Medicare, Health Affairs Forefront, August 25, 2023, by Alain C. Enthoven

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Modernizing Medicare, edited by Robert Moffit and Marie Fishpaw (Johns Hopkins Press), is a “must read” for all those concerned with public finances and health policy — though not an easy read because of the great complexity of the Medicare program.

This book, with chapters by leading authorities, explains how and why a new model, based on informed cost-conscious consumer choice among competing private health plans is the most promising — indeed the only practical — solution to the problem of soaring health care costs.

In his introduction, Robert Moffit traces the evolution of thinking by policy makers from the 1965 defined benefit fee-for-service program covering hospital and physicians’ services to the present thinking favoring the defined contribution model and consumer choice among competing health plans. The idea has gained bipartisan support. The latter model, now called Medicare Advantage, is the choice of half of all Medicare beneficiaries.

All of the chapters are worth reading, but in the interest of brevity, let me focus on three that merit particular attention.

Charles Blahous concludes persuasively that “Medicare as we know it cannot be preserved unless it is significantly changed,” while more American seniors are deciding that “Medicare Advantage meet their needs more effectively than does traditional Medicare.”

John Goodman explains some of the many ways even Medicare Advantage could be improved. Goodman notes that some practices offer “direct primary care” or 24/7 access to a primary care physician for a telemedicine consultation for a fixed monthly fee. Also, Goodman reports success with “reference pricing.”

Edmund Haislmaier proposes an idea that would be new to the health insurance market but imported from successful application elsewhere: risk transfer pools. Government would start by paying plans on the basis of the populations and counties they serve. Then all participating plans would participate in a self-governing pool in which the participants would negotiate an agreed upon equitable sharing of payments for the costs of high-cost patients.

An important read, Modernizing Medicare will become the guidebook for the inevitable changes that must be made in Medicare.

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Comment (Health Affairs):

By dmccanne

If there is to be competition, it seems that it should be between the health care professionals and institutions based on the services they provide.

The primary mission of the private financial administrators, that is the private insurers, is to maximize profits for their investors thereby creating more billionaires; thusly they compete for the public and private health care dollars. In contrast, the primary mission of public financial administrators, such as those managing the traditional Medicare program, is to deliver health care to those who need it, for the public good rather than for the purpose of wealth building.

Traditional Medicare does need some improvement in its benefits, but we need to abolish the private entities that are drawing billions of dollars out of our health care system through private equity and, in the meantime, assuming ownership of physician groups and other professionals.

Einav and Finkelstein in “We’ve Got You Covered,” have shown that we can have automatic coverage for everyone that is free at the point of service and that everyone can afford by funding it with a progressive income tax. Unfortunately, Moffit, Fishpaw and their conservative authors in “Modernizing Medicare,” direct their reform to “harnessing the power of market competition” by giving our health care dollars to the entrepreneurs to satisfy their own mercenary priorities. Wrong solution.

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Comment:

By Don McCanne, M.D.

This book review by professor Alain Enthoven of Stanford purports to be a prescription for what ails Medicare. Unfortunately, the book’s contributors – many widely known in health economics – are driven by their belief that remedies must be based on market competition, rather than health policy that primarily benefits patients. Market competition as practiced in the United States is designed primarily to build wealth for investors. That is hardly the prescription we want to see for our egregiously expensive health care.

There are now extensive reports about how our public and private health care dollars are being misspent on the Medicare Advantage program. Yet it has been so successfully marketed that it has become, quite inappropriately, the choice of over half of the Medicare beneficiaries. The conservative, market-oriented authors of this book are advocating the “modernization” of Medicare by further advancing the unfortunate Medicare Advantage model.

So what prescription do we need for what ails Medicare? We can improve its benefits (vision, hearing, long term care, etc.), eliminate cost sharing, expand it to cover everyone, and fund it equitably through a progressive income tax; in other words by converting it to a single payer, Medicare for All program.

It would be nice if Health Affairs would publish an article describing the moral imperative and beneficial efficiency of the single payer model.

http://healthjusticemonitor.org…

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Summary: The man who as a federal policy official drove the privatization of Medicare then jumped to the private sector and profited massively from the changes. Others follow the same pattern. Clever investors make billions of dollars. The rest of us suffer the consequences in higher costs and lower access to care.

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Patient Zero, Tom Scully is as responsible as anyone for the way health care in America works today, The American Prospect, August 1, 2023, by David Dayen

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It was late 2002, and Tom Scully, administrator of the Centers for Medicare & Medicaid Services (CMS), was at a U.S. News and World Report forum, relating a tale of hospital skullduggery. Under CMS rules, Medicare reserved 5.1 percent of its budget to compensate hospitals that treated “outlier” high-cost patients. Scully, a youthful-looking man with a pile of slightly graying hair who talked a mile a minute, explained that Tenet and several other hospital systems, without the regulators knowing, had for years randomly jacked up prices on individual patients to access the set-aside. This deprived other hospitals that actually had sick patients from getting a higher share of the funds; the dishonest actors were costing the honest ones money.

Scully didn’t blame hospital deception, but the policy framework he was hired to manage. “I love Medicare, it’s a great program, but as an insurance model, it’s a joke,” he said, explaining that his regulators were outgunned and slow to react. The hospitals falsified patient costs and that was unethical, he conceded, but they were just responding to incentives. “People follow the money,” Scully said, “and they’ll find the little niches in the program and they’ll game it, and that’s what happened here.”

One reading of the history of health care over the past half-century, as the profit motive was gradually introduced into insurance and delivery systems, is that little niches have sprung up, and people with capital have taken advantage. That would include Tom Scully.

At the Office of Management and Budget (OMB) in the first Bush administration and CMS under Bush II, Scully played a major role in many of the defining features of health care today, from Medicare Advantage and the privatized Part D prescription drug benefit to risk adjustment and the physician payment schedule. He wasn’t responsible for Obamacare, but the program closely follows his desire to solve problems through the private sector.

When Scully left CMS in late 2003, he joined Welsh, Carson, Anderson & Stowe, perhaps the leading health care–focused private equity firm, where he used his knowledge and contacts to invest in companies that were poised to capitalize on the incentives the government offered. Welsh Carson helped pave the way for what is now an investor gold rush into the medical system.

The 1992 Bush health plan at least rhymes with what passed 18 years later as Obamacare.

I’ve watched and listened to virtually every scrap of tape of Scully over the last 35 years, and I conducted a long interview with him in June. I think his beliefs are sincere. He thinks government price-setting doesn’t work, and that empowering private insurers that put their own money at risk leads to better and more efficient care. He believes poor people should be covered generously, but all other patients exposed to cost to reduce overutilization. And he wants the best hospitals and nursing homes and clinics to be paid more than the worst, to force advances in quality.

In practice, this set of philosophies has created the monster that is America’s health care system, where most of the money is public, but most of the entities dishing out and getting that money are private. Commercialization has crowded out what was a thriving nonprofit impulse; intensifying mergers and acquisitions have concentrated every aspect of the system; and a plague of middlemen each take their cut. Scully’s fear of big-government price-fixers has led to the triumph of big private profit-takers, at the cost of doctors, nurses, and patient care.

More than anything, the system has become maddeningly complex, with armies of functionaries working every angle, straddling every ethical line, to unlock a big safe full of money. Scully is America’s safecracker-in-chief. He designed so many aspects of this system, with its intricate nooks and crannies, that he’s practically the only person who understands it. That makes him an extremely valuable commodity. It’s almost as if he invented his career outside of government when he was transforming it on the inside.

… [read on for details on the misguided history of privatization of Medicare through Part D and Medicare Advantage, fostering a private equity explosion, and how this financially benefited Scully and other investors]

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Comment:

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

Again, The American Prospect series on health care displays for depressing scrutiny the utter failure of our 21^st century health insurance morass to work for patients, instead favoring inside-game investors like Tom Scully and legions of others. Medicare Advantage plans game the CMS-created system to overcharge by more than $75 billion per year, and private equity companies reap many billions more.

How can this unsavory reality not lead us to complete disgust with decades of rising privatization of health coverage, especially publicly funded? Our fragmented and exploited system utterly fails, driving up costs and profits while depriving patients of access and financial protection.

That Scully fostered and then prospered from ill-conceived free market theories is galling.

The solution? Place our faith in a universal public health insurance system. Remove profit incentives and opportunities from the task of paying for health care, and rein it in for care provision. As do dozens of other wealthy countries. Single payer.

http://healthjusticemonitor.org…

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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.