PNHP

Health Policy Issues in the Presidential Race

Health Policy Issues in the Presidential Race

Donald Trump would replace the ACA, he says, but with what? His past proposals suggest ACA and Medicaid tightening. Kamala Harris would strengthen the ACA, she says, and limit out-of-pocket drug costs in Medicare and beyond. Neither supports single payer.

The “Concept of a Plan” President Trump Proposed to Replace the ACA, KFF QUICKTAKES, September 11, 2024, by Larry Levitt

When asked in the debate whether he had a replacement plan for the Affordable Care Act, former President Donald Trump said he had the “concepts of a plan.”

If you look at Trump’s record as president, there is truth in that statement. He did, in fact, propose the concept of an ACA replacement plan in his 2020 budget, though it has never gotten much attention.

Trump’s conceptual ACA replacement plan would have repealed the ACA’s premium subsidies and Medicaid expansion, replacing them with a block grant to states. It also would have capped federal Medicaid spending. All told, Trump’s plan would have reduced federal spending on the ACA and Medicaid by over $1 trillion over a decade.

Trump also proposed providing “relief” from the ACA’s “insurance rules and pricing restrictions.”

Trump has long talked about making the ACA less expensive, but the question is less expensive for whom. Trump’s past proposals would certainly have made the ACA less expensive for the federal government, but with the trade-off of higher out-of-pocket premiums for people, more uninsured, and higher spending and greater risk for states.

Polling: Harris v. Trump on Key Health Care Issues, KFF, September 10, 2024, by Ashley Kirzinger, et al.

How Voters Are Prioritizing Health Care Issues in 2024: The economy and inflation continue to dominate the list of issues that voters are focusing on during this year’s presidential election with four in ten voters (38%) saying it is the most important issue determining their vote in the 2024 presidential race. Following the economy is threats to democracy (22%), immigration and border security (12%), then several individual health care issues including: abortion (7%), Medicare and Social Security (7%), and health care costs including prescription drugs (5%). Altogether, health care issues are seen as the most important issue by about one in five voters (19%). Gun policy (3%) and the war between Israel and Hamas in Gaza (2%) rank the lowest among the issues included in the list provided to voters.

Voters Want to Hear Candidates Talk About Lowering Health Care Costs: An indication of how the economy and health care consistently overlap for voters, economic concerns also rear up when voters are asked what health care issue they most want to hear the candidates talk about. Across partisans, the recurring theme is costs. Responses related to health care costs are offered by four in ten (42%) Democratic and Democratic-leaning independent voters when asked to say in their own words what is the one health care issue they would most like Vice President Harris to talk about. This includes voters who mentioned general health care costs (20%), prescription drug costs (15%), and the cost of insurance or reducing their monthly premiums (6%). About one in seven offered abortion as the one health care issue they want Harris to talk about and 13% mentioned universal health care – an issue that was largely debated during the 2020 Democratic primaries.

Comment:

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

Health issues are fairly high profile In this presidential campaign – collectively, the most important issue for one in five voters. Abortion is seen as the leading election issue for 7% of voters. Medicare & social security (combined, oddly in my view) are also at 7%, and health care costs are at 5%.

Trump proposes to replace the ACA with something TBD cheaper and better. His actual approach, per his 2020 federal budget request, seems to be repealing ACA premium subsidies and Medicaid expansion, placing these programs into state block grants. Which would cut federal costs by >$1 trillion over 10 years. Also, end the ACA’s “insurance rules and pricing restrictions.” This is all consistent with Project 2025, as summarized in HJM. He waffles on abortion, but is largely seen as a threat to abortion rights.

Harris aims to strengthen the status quo. She proposes to strengthen the ACA: to make permanent COVID subsidy increases and fix a “family glitch”. For drug prices she favors accelerating Medicare drug price negotiations, and extending two caps in Medicare ($35 insulin copay and drug out-of-pocket total) to the entire population. She wants to end drug companies blocking competition and abusive practices of drug intermediaries. She avidly supports abortion rights.

See a side-by-side comparison here.

Drew Altman notes that the “do not mention” program is Medicaid, since Medicare and the ACA are considered higher priority for voters. Yet the consequences for Medicaid are substantial, per above.

Of course, Medicare for All / single payer gets no favorable mention – despite its ability to sharply reduce health care costs for families, a leading concern of voters. Instead, it is used by Trump to attack Harris since pre-2020 she endorsed Bernie Sanders M4A bill. Don’t expect Harris to return to single payer. But if state reform efforts, such as currently in Oregon and California, are to garner federal regulatory cooperation (“waivers”), a Harris administration may be more flexible.

https://healthjusticemonitor.org…

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Incredible (Terrible) Shrinking Physician Supply

Waiting times for physician appointments are growing. The immediate cause is contraction of the physician workforce. The root cause is clinician burnout, in large part due to fragmented insurance and resulting make-work inefficiencies. Single payer will help.

Health shrinkflation: Patients wait more for less, Axios, September 3, 2024, by Tina Reed

The U.S. spends more on health care than almost anywhere else. But increasingly patients are getting less in return, and enduring long waits to get not as much face-time with their clinician.

Why it matters: Shrinkflation is hitting a sector that accounts for almost one-fifth of the economy, eroding the doctor-patient relationship and leaving many turning to urgent care clinics or telehealth services.

  • Some who can afford it are gravitating to concierge practices that offer fewer hoop jumps and more add-on services with office visits.

The latest: The trend is being felt especially in primary care, but also in many specialties.

  • An Axios-Ipsos survey last month found that nearly one in five respondents said they had to wait more than two months to see a primary care physician or specialist, with waits trending longest in the Midwest.
  • NYC Health + Hospitals recently told primary care doctors to cut appointment times in half to 20 minutes, in order to squeeze in more patients, Gothamist reported.
  • A spokesperson told Axios that the public health system is grappling with 50,000 more primary care patients who’ve been added since 2021. The average number of days to the third next available appointment jumped from 12 days to 22 days.

By the numbers: 17% of patients had to wait one to three months for their latest doctor’s appointment, per electronic health records company Tebra.

  • The most frequently cited specialties with long wait times included neurology (26%), ear, nose, and throat (26%), psychiatry (20%), and OB/GYN (17%). Primary care stood at 19%.
  • 43% of patients reported experiencing longer wait times for appointments since the pandemic, per the Tebra survey.
  • The surge in demand for in-person care since the crisis has been well-documented. AMN/Merritt Hawkins found that the average wait time for a physician appointment in 15 large metro markets surveyed in 2022 was 26 days, up from roughly 24 days in 2017, and about 21 days in 2004.

The big picture: This is what shrinkflation in healthcare looks like as the industry struggles with supply and demand issues, Robert Pearl, a Stanford University professor and former CEO of The Permanente Medical Group, told Axios.

  • There’s been across-the-board growth in patient volumes largely from pent-up demand for services many put off during the pandemic.
  • At the same time, tens of thousands of doctors have left the field due to burnout and other factors, and surveys indicate even more plan to retire early.
  • Red tape around insurance and rising out-of-pocket costs are leaving patients frustrated and confused, and in some cases burdened by more medical debt.

“You’re paying actually more for your health coverage, but you’re not getting more. You’re actually getting less,” Pearl said.

Comment:

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

The physician supply is steadily contracting, especially in primary care. This lengthens waits for clinical visits, not to mention the challenge of finding a new provider. Each year we pay more in premiums and cost-sharing, yet we suffer increasing challenges getting the care we need.

What’s going on? This tightening of physician supply reflects some simple math: more individuals leave clinical medicine than new trainees enter. Increasing the number of mid-level providers, like nurse practitioners, is a viable and valuable option. However, the physician flow dynamics remain critical. And recent trends are not encouraging:

This is ongoing: 7% of physicians left the workforce in 2021 and 2022. Nearly 1 in 4 physicians stated an intention to leave practice within two years. Long-term projections for physician supply are dire.

Why are so many doctors leaving? The short answer is growing burnout:

And why the burnout?

  • Too many bureaucratic tasks (eg, charting, paperwork): 62%
  • Too many hours at work: 41%
  • Lack of respect from administrators / employers, colleagues, staff: 40%
  • Insufficient compensation: 38%
  • Lack of control / autonomy: 32%
  • Full list here

All of these causes reflect, in substantial degree, our fragmented insurance system and the central role of for-profit insurers and provider groups. Here’s how single payer would help with each:

  • Reduce bureaucracy: eliminate an hour/day of billing & insurance-related tasks done by physicians.
  • Reduce hours at work: less time on bureaucracy; more providers especially in primary care.
  • Build respect: bolster the clinical role of physicians, and foster clinician-run practices.
  • Correct compensation inequities: Increase payment rates for primary care.
  • Build autonomy: make clinician-run practices more financially and administratively viable.

Single payer isn’t a magic potion for physician emotional well-being. But it is a viable framework to build clinical focus and autonomy, and to foster equity among specialties (and of course among populations groups). It is the only way to break out of our burnout quagmire.

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.

“Shocking”: Experts warn “irresponsible” Project 2025 Medicare proposal would harm seniors

"We've invited for-profit corporations to drain the Medicare Trust Fund 
 and we overpay them to kill people"

By Cara Michelle Smith
Salon, September 3, 2024

Something still haunts Ed Weisbart, MD, from his days in the health insurance business.

It was 1999, and Weisbart was the medical director of a Chicago medical group that managed care for more than 140,000 people. The enterprise was running like a well-oiled machine — until one day, a man presented with a rare blood clotting disorder that would cost the company $1 million a year to treat. At that sum, one of its regional offices would likely go out of business.

Weisbart caught himself entertaining dark thoughts. What if the company just gave this guy the cold shoulder? Could they simply not answer his calls? These were “paper records days,” he said — in theory, the company could lose his medical records. If he showed up at the office to meet with anybody, maybe they could make him wait an hour or two.

“And then, what? He would complain to us, and say this used to be a good office, and it’s not anymore – I’m going to go somewhere else,” Weisbart said. “And I would be thinking, I won.”

Weisbart never acted on any of these impulses, he said, nor did he tell anybody about those thoughts until years later. The office didn’t go out of business, either, and the man received his treatments. But the temptation toward corruption left a deep impact.

“It’s haunted me ever since,” Weisbart said. “I consider myself a generally ethical patient advocate, and yet, I was so corrupted by the finances of the system that I was actually developing schemes to make a very sick person not want to get health care with us. And isn’t the point of a health care system that you should want to get health care?”

Today, Weisbart is the national secretary for Physicians for a National Health Plan (PNHP), an advocacy group representing more than 25,000 physicians who support a national health insurance plan and oppose a profit-driven health insurance system in which companies can choose profits over patients. That system’s interests are at the heart of a stunning Medicare proposal in Project 2025, the Heritage Foundation’s 900-page right-wing agenda for a second Trump administration that experts say would harm patients while enabling insurance companies to funnel billions of dollars in desperately needed funds from the Medicare program.

“It’s kind of shocking, when it comes to how irresponsible it is,” Andrea Ducas, vice president of health policy at the Center for American Progress, told Salon of Project’s 2025 proposed change to Medicare. “It’s emblematic of a desire to, essentially, increase corporate power.”

Project 2025 proposes making Medicare Advantage, as opposed to traditional Medicare, the default plan for all enrollees. Medicare Advantage has been around for decades; it was signed into law in 1997 as part of a bipartisan reform bill to balance the federal budget. Under Medicare Advantage, insurance companies offer plans that cover Medicare benefits. In turn, Medicare pays the insurance companies based on an estimate of an individual’s annual health care costs.

In theory, the Medicare Advantage program was supposed to help the government benefit from the private sector’s efficiencies. In practice, many insurers overcharge the federal government hundreds of billions of dollars in inflated estimates, often by adding diagnosis codes that make individuals appear sicker on paper than they are in reality. MedPac, a nonpartisan Congressional advisory committee, estimates that in 2024, inflated estimates will translate to $50 billion in overpayments. An analysis from PNHP, published in 2023, estimates that Medicare overpays insurers by as much as $140 billion per year.

In one analysis of Medicare Advantage data, The Wall Street Journal found that between 2019 and 2021, individuals enrolled in Medicare Advantage through UnitedHealth were roughly 15 times as likely to be diagnosed with diabetic cataracts than traditional Medicare beneficiaries. Payments to insurers for diabetic cataracts totaled $700 million in that period; most diagnoses were added by the insurers.

“The plans will get more for people who are more sick, so there’s significant incentive for the plans to make their enrollee population appear as sick as possible,” David Lipschutz, co-director of the Center for Medicare Advocacy, told Salon.

According to an analysis from Lever, an investigative newsroom, the private insurance giant Humana — one of the largest providers of Medicare Advantage plans — recorded $2.8 billion in profits in 2022. Without federal government overpayments into Medicare Advantage plans, though, Humana may have lost nearly $900 million that year.

“We overpay them to kill people”

Outside those abuses, Medicare Advantage doesn’t offer a better patient experience. In many instances, it can be worse.

Medicare Advantage beneficiaries are often limited to a smaller provider network, deal with more prior authorizations and are more often “inappropriately denied approval for necessary health care,” according to PNHP. In 2022, KFF found that those enrolled in Original Medicare were more often treated in higher-rated specialty healthcare facilities than those in Medicare Advantage.

Those consequences don’t exist in a vacuum: Medicare Advantage patients undergoing surgeries for certain liver, pancreas and stomach cancers had higher mortality rates than similar patients on Original Medicare, according to PNHP.

“We’ve created a system where we’ve invited for-profit corporations to drain the Medicare Trust Fund . . . and we overpay them to kill people,” Weisbart said.

A broader implication for the conservative movement

That Medicare Advantage’s patient harms are so well-documented, and that Project 2025 recommended that the plan replace Original Medicare, may belie a core truth of the modern American conservative movement, Kim Phillips-Fein, a historian and professor at Columbia University, told Salon.

“A lot of the less-visible parts of the project are going to wind up reinforcing economic inequality,” Phillips-Fein said of Project 2025. “They talk one way, but are very likely to govern another.”

Much of today’s modern conservative movement is rooted in the business community’s antagonism against the New Deal, Phillips-Fein said, which ushered in what corporate stakeholders saw as a large labor movement that threatened business interests. But by promoting a health care plan proven to harm individuals, Project 2025’s Medicare Advantage proposal — as well as the broader Project 2025 agenda — suggests that corporate interests aren’t just a component of the American conservative movement. Rather, it suggests that those interests are at the core of the movement — even at the known harm of the American worker.

“It’s just telling that you’ve got an authoritarian playbook that sort of, at every pass, seems to be more focused on driving up corporate profits at the expense of the American people,” Ducas said.

Reinvesting “the giant bag of cash” in traditional Medicare

Medicare Advantage was pitched as a private market solution to traditional Medicare. It exists because of the flaws of traditional Medicare. But experts say Medicare Advantage’s own shortcomings present a timely opportunity for the program to reign in fraudulent spending and reinvest funds into the original program.

“We can take these significant and wasteful overpayments, reinvest them into the Medicare program . . . and that rising tide would help all Medicare beneficiaries, because that would then become a new baseline,” Lipschutz said.

One badly needed reform? Adding an out-of-pocket cap to traditional Medicare plans. With no limit on out-of-pocket spending, beneficiaries can spend more than $5,000 per year on premiums. In 2018, those enrolled in traditional Medicare spent an average of $6,168 per year on premiums and services.

Another area ripe for reform: covering vision, dental and hearing under traditional Medicare, Ducas said. Under the current program, Medicare enrollees have to purchase a supplementary plan that covers the above health care as well as an extra plan known as Medigap, which reduces out-of-pocket costs associated with Medicare and the supplemental coverage.  On average, Medigap monthly premiums can range from $50 to more than $300.

Without reform to Medicare Advantage, the broader Medicare program is projected to overpay insurers by more than $7 trillion over the next ten years, according to the Department of Health and Human Services.

“As it would happen, there is a giant bag of cash we are, right now, throwing every year at Medicare Advantage plans,” Ducas said. “If we took that waste out . . . you could get to that reform future. That’s what excites me.”

https://salon.com…

Greenbrier employees plight shows need for different system

By Dan Doyle, M.D.
The Real WV, Letters, September 1, 2024

The nearly 2000 employees of the Greenbrier Resort were informed on August 19 that they would lose their health care insurance because the company had not paid their insurance premiums for the past four months. A last-minute deal on August 29 continued their coverage for now, but the future remains uncertain.

As a family physician with over 40 years practice in southern West Virginia, I find this cruel and outrageous.

The trauma suffered by these employees is one more example of why the current Employer Sponsored Insurance (ESI) system does not serve the American people well. Even with Medicare and Medicaid, the current system still leaves 28 million Americans and 106,000 West Virginians uninsured. Instead, we should have a non-profit, single-payer system that covers every American from birth to death. Workers’ health insurance would be portable instead of constantly endangered by corporate decisions, layoffs, or just plain corrupt management.

Self-employed workers, low-income service workers, and young people (19-24) are the ones most likely to go bare facing potential bankruptcy every day from an accident, sudden illness, or complications of chronic disease.

Two bills introduced before the U.S. Congress would correct this situation. HB3421 with lead sponsor Pramila Jayapal (D-WA) and SB.1655 with lead sponsor Bernie Sanders (I-VT) lay out details for transitioning US health care from an employer-based system to an improved Medicare for All system. Everyone would be covered birth to death and not face the uncertainty currently experienced by the Greenbrier employees.

The moral case for such a system is easy. Health care is a human right. No man, woman, or child in the wealthiest nation on earth should go without.

The economic case is also strong. Numerous policy studies have demonstrated that for what the U.S. is spending on health care now, every one could be covered. But it would require controlling run-away drug prices and corporate greed that places profits over patient care.

That’s why the politics is hard. There is so much money at stake to keep the current unjust, dysfunctional system in place.

Physicians for a National Health Program (PNHP) has been educating and advocating for such a system since 1985. The WV chapter of PNHP is working statewide to inform our patients, our colleagues, health professions students, and our elected representatives about the availability and feasibility of improved Medicare for All.

We won’t quit until everyone is covered. Everybody in, nobody out.

https://therealwv.com…

Saving Private Practice

The American Medical Association (the AMA) is pleading with Congress to save teetering independent medical practice. Of course, one ask is higher pay. But equity and lower administrative burden are right up there. Is organized medicine finally supporting single payer?

Is private practice collapsing? Congress can help stem the tide, AMA, August 23, 2024, by Tanya Albert Henry

It’s time for lawmakers to recognize the threats to independent medical practices and time to take “immediate and decisive actions” to stop driving physicians away from private practice, the AMA told Congress.

“The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations and systemic inequities,” the AMA said in a statement submitted to the House Ways and Means Committee (PDF) for its hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.”

The AMA urged Congress to pass comprehensive legislative reforms that create:

  • Equitable payment models.
  • Reduced administrative burdens.
  • Expanded support for rural and underserved areas.
  • A health care infrastructure secured from emerging threats.

Re: The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine, STATEMENT of the American Medical Association, U.S. House of Representatives Committee on Ways and Means, May 23, 2024

The American Medical Association (AMA) appreciates the opportunity to submit the following Statement for the Record to the U.S. House Committee on Ways and Means as part of the hearing entitled, “The Collapse of Private Practice: Examining the Challenges Facing Independent Medicine.” The AMA commends the Committee for addressing this critical issue that threatens the very existence of private medical practices. The AMA is fighting tirelessly to combat the financial and regulatory challenges that jeopardize the survival of these practices. The situation is dire and multifaceted, involving not only the fallout from the COVID-19 pandemic, but also drastic cuts in physician practice payments relative to inflation, surging practice costs, and overwhelming administrative burdens. These payment reductions and burdens are forcing more and more physicians to either close their doors or merge with larger health care systems, severely limiting competition and patient choice. While the pandemic has amplified existing financial pressures and highlighted the urgent need for continued legislative intervention, the relentless cuts in physician practice payments present an immediate and existential threat to private practices.

CONCLUSION

The AMA implores Congress and all stakeholders to recognize the imminent and severe threats to independent medical practices. The fabric of our health care system, woven with the dedication and expertise of these practices, is unraveling under the compounding pressures of unsustainable financial models, burdensome regulations, and systemic inequities. We urge immediate and decisive action to correct the course with comprehensive legislative reforms that ensure equitable payment models, reduce administrative burdens, expand support for rural and underserved areas, and secure our health care infrastructure against emerging threats. The AMA and physician community stand ready to work with Congress to preserve the legacy and future of independent physician practices, ensuring that they continue to provide high-quality, personalized care to all communities across the nation. This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.

Comment:

By Don McCanne, M.D.

For well over half a century, the AMA has seemed to be opposed to government involvement in health care such as through a national health care program like single payer Medicare for All. Although the original Medicare program was accepted because it did provide coverage to all of our senior citizens, including those previously unable to afford medical care, there was some reluctance because of concerns about the government being involved in ensuring adequate funding and appropriate regulatory oversight. There was still strong support for private funding through cash payments or private insurance, especially employer-sponsored plans. There was also the recognition of a need for funding care for the truly indigent, such as Medicaid and other government programs.

So what has happened to this system that the AMA refused to replace with a comprehensive system for everyone? The physicians believed that, as long as they remained in control, they could continue to practice on their own terms, taking good care of the physicians, even though the patients may not have fared as well without more comprehensive government oversight.

But look at what has happened as they encouraged the private sector to maintain and expand control of health care in America. Private equity has moved in and managed to convert the primary mission of the health care system from maintaining the health of the patients to placing the creation of individual wealth of the owners as the highest priority. The private insurance industry has been particularly adept at gaining control of the medical-industrial complex with a private regulatory system that is designed to move those health dollars to their own coffers. The physicians who believed that they could continue to practice on their own terms have now found out that their terms are being dictated to them as they have actually been placed in a position of themselves being chattel that are bought and sold by this nefarious industry.

Now how does the AMA feel about the government being involved in the provision of health care? The system is such a disaster that has created a massive burnout of the profession that they are actually going to Congress – the government! – to plead that the government finally does something about it.

It is interesting that most of the requests are not simply to increase their net income, but also to make the system work better by creating an environment in which physicians are more comfortable in caring for their patients. Many of the these proposed changes will create a health care environment that does improve care for the patients as well. You see, though physicians want a system that works well for them, they are not opposed to a system that works well for the patients.

As you examine the list of improvements that the physicians are requesting (See Statement to Congress), you can see that the list could be readily modified to create a system that works well for both physicians and their patients. And we already know that enacting and implementing a single payer Medicare for All system would be the most effective for all parties concerned.

We really do want the government involved, and the AMA has now opened the doors as they stand ready to work with Congress. As they say in their Statement to Congress, “This is not just a call for action; it is a plea to safeguard the heart of American health care before it is too late.”

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.

Feds killed plan to curb Medicare Advantage overbilling after industry opposition

By Fred Schulte
CBS News via KFF Health News, August 28, 2024

A decade ago, federal officials drafted a plan to discourage Medicare Advantage health insurers from overcharging the government by billions of dollars — only to abruptly back off amid an “uproar” from the industry, newly released court filings show.

The Centers for Medicare & Medicaid Services published the draft regulation in January 2014. The rule would have required health plans, when examining patient’s medical records, to identify overpayments by CMS and refund them to the government.

But in May 2014, CMS dropped the idea without any public explanation. Newly released court depositions show that agency officials repeatedly cited concern about pressure from the industry.

The 2014 decision by CMS, and events related to it, are at the center of a multibillion-dollar Justice Department civil fraud case against UnitedHealth Group pending in federal court in Los Angeles.

The Justice Department alleges the giant health insurer cheated Medicare out of more than $2 billion by reviewing patients’ records to find additional diagnoses, adding revenue while ignoring overcharges that might reduce bills. The company “buried its head in the sand and did nothing but keep the money,” DOJ said in a court filing.

Medicare pays health plans higher rates for sicker patients but requires that the plans bill only for conditions that are properly documented in a patient’s medical records.

In a court filing, UnitedHealth Group denies wrongdoing and argues it shouldn’t be penalized for “failing to follow a rule that CMS considered a decade ago but declined to adopt.”

This month, the parties in the court case made public thousands of pages of depositions and other records that offer a rare glimpse inside the Medicare agency’s long-running struggle to keep the private health plans from taking taxpayers for a multibillion-dollar ride.

“It’s easy to dump on Medicare Advantage plans, but CMS made a complete boondoggle out of this,” said Richard Lieberman, a Colorado health data analytics expert.

Spokespeople for the Justice Department and CMS declined to comment for this article. In an email, UnitedHealth Group spokesperson Heather Soule said the company’s “business practices have always been transparent, lawful and compliant with CMS regulations.”

Missed diagnoses

Medicare Advantage insurance plans have grown explosively in recent years and now enroll about 33 million members, more than half of people eligible for Medicare. Along the way, the industry has been the target of dozens of whistleblower lawsuits, government audits, and other investigations alleging the health plans often exaggerate how sick patients are to rake in undeserved Medicare payments — including by doing what are called chart reviews, intended to find allegedly missed diagnosis codes.

By 2013, CMS officials knew some Medicare health plans were hiring medical coding and analytics consultants to aggressively mine patient files — but they doubted the agency’s authority to demand that health plans also look for and delete unsupported diagnoses.

The proposed January 2014 regulation mandated that chart reviews “cannot be designed only to identify diagnoses that would trigger additional payments” to health plans.

CMS officials backed down in May 2014 because of “stakeholder concern and pushback,” Cheri Rice, then director of the CMS Medicare plan payment group, testified in a 2022 deposition made public this month. A second CMS official, Anne Hornsby, described the industry’s reaction as an “uproar.”

Exactly who made the call to withdraw the chart review proposal isn’t clear from court filings so far.

“The direction that we received was that the rule, the final rule, needed to include only those provisions that had wide, you know, widespread stakeholder support,” Rice testified.

“So we did not move forward then,” she said. “Not because we didn’t think it was the right thing to do or the right policy, but because it had mixed reactions from stakeholders.”

The CMS press office declined to make Rice available for an interview. Hornsby, who has since left the agency, declined to comment.

But Erin Fuse Brown, a professor at the Brown University School of Public Health, said the decision reflects a pattern of timid CMS oversight of the popular health plans for seniors.

“CMS saving money for taxpayers isn’t enough of a reason to face the wrath of very powerful health plans,” Fuse Brown said.

“That is extremely alarming.”

Invalid codes

The fraud case against UnitedHealth Group, which runs the nation’s largest Medicare Advantage plan, was filed in 2011 by a former company employee. The DOJ took over the whistleblower suit in 2017.

DOJ alleges Medicare paid the insurer more than $7.2 billion from 2009 through 2016 solely based on chart reviews; the company would have received $2.1 billion less if it had deleted unsupported billing codes, the government says.

The government argues that UnitedHealth Group knew that many conditions it had billed for were not supported by medical records but chose to pocket the overpayments. For instance, the insurer billed Medicare nearly $28,000 in 2011 to treat a patient for cancer, congestive heart failure, and other serious health problems that weren’t recorded in the person’s medical record, DOJ alleged in a 2017 filing.

In all, DOJ contends that UnitedHealth Group should have deleted more than 2 million invalid codes.

Instead, company executives signed annual statements attesting that the billing data submitted to CMS was “accurate, complete, and truthful.” Those actions violated the False Claims Act, a federal law that makes it illegal to submit bogus bills to the government, DOJ alleges.

The complex case has featured years of legal jockeying, even pitting the recollections of key CMS staff members — including several who have since departed government for jobs in the industry — against those of UnitedHealthcare executives.

Red herring

Court filings describe a 45-minute video conference arranged by then-CMS administrator Marilyn Tavenner on April 29, 2014. Tavenner testified she set up the meeting between UnitedHealth and CMS staff at the request of Larry Renfro, a senior UnitedHealth Group executive, to discuss implications of the draft rule. Neither Tavenner nor Renfro attended.

Two UnitedHealth Group executives on the call said in depositions that CMS staffers told them the company had no obligation at the time to uncover erroneous codes. One of the executives, Steve Nelson, called it a “very clear answer” to the question. Nelson has since left the company.

For their part, four of the five CMS staffers on the call said in depositions that they didn’t remember what was said. Unlike the company’s team, none of the government officials took detailed notes.

“All I can tell you is I remember feeling very uncomfortable in the meeting,” Rice said in her 2022 deposition.

Yet Rice and one other CMS staffer said they did recall reminding the executives that even without the chart review rule, the company was obligated to make a good-faith effort to bill only for verified codes — or face possible penalties under the False Claims Act. And CMS officials reinforced that view in follow-up emails, according to court filings.

DOJ called the flap over the ill-fated regulation a “red herring” in a court filing and alleges that when UnitedHealth asked for the April 2014 meeting, it knew its chart reviews had been under investigation for two years. In addition, the company was “grappling with a projected $500 million budget deficit,” according to DOJ.

Data miners

Medicare Advantage plans defend chart reviews against criticism that they do little but artificially inflate the government’s costs.

“Chart reviews are one of many tools Medicare Advantage plans use to support patients, identify chronic conditions, and prevent those conditions from becoming more serious,” said Chris Bond, a spokesperson for AHIP, a health insurance trade group.

Whistleblowers have argued that the cottage industry of analytics firms and coders that sprang up to conduct these reviews pitched their services as a huge moneymaking exercise for health plans — and little else.

“It was never legitimate,” said William Hanagami, a California attorney who represented whistleblower James Swoben in a 2009 case that alleged chart reviews improperly inflated Medicare payments. In a 2016 decision, the 9th Circuit Court of Appeals wrote that health plans must exercise “due diligence” to ensure they submit accurate data.

Since then, other insurers have settled DOJ allegations that they billed Medicare for unconfirmed diagnoses stemming from chart reviews. In July 2023, Martin’s Point Health Plan, a Portland, Maine, insurer, paid $22,485,000 to settle whistleblower allegations that it improperly billed for conditions ranging from diabetes with complications to morbid obesity. The plan denied any liability.

A December 2019 report by the Health and Human Services Inspector General found that 99% of chart reviews added new medical diagnoses at a cost to Medicare of an estimated $6.7 billion for 2017 alone.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

https://cbsnews.com…

The Pursuit of Single Payer: Toppling, or Tipping Point?

November 2024 is thirty years after we lost California’s single payer ballot initiative. I look back at what has happened since, and see promise ahead.

Comment:

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

This morning, as I pondered writing a broad update on our quest for single payer, I realized that the movement in California, and my involvement, is fast approaching its 30th birthday. In November 1994, Proposition 186 was on the California ballot. We won 
 in San Francisco and Berkeley 
 but lost statewide, by the lopsided margin of 27% yes, 73% no. We were seriously outgunned by the insurers, abetted by various health care interest groups protecting their profitable interests in the existing system.

A lot has happened and changed in the intervening three decades. It’s not a pretty picture. US health care spending jumped from twice the average of other wealthy nations to three times as high, while our longevity fell from roughly equal to four years behind. The Affordable Care Act passed in 2010, cutting the uninsured rate from about 16% to 8%, while hugely boosting under-insurance by encouraging high deductible plans. Medicare Advantage, accelerated by the ACA, caught up and surpassed traditional Medicare, with annual overcharges in excess of $100 billion, making insurers the largest beneficiary of US government largesse. UnitedHealth, a massive insurer, became a multisector leviathan, adding pharmacy benefit management, pharmacies, and physicians. Private equity now controls broad swaths of the provider world. We spend at least $700 billion per year — $2000 per person – in profits and administrative waste, as nearly half of adults report financial barriers to care each year. Overall, we might say that the corporatization of medicine has triumphed over using health care funds for health care. All while three dozen other wealthy nations demonstrate the efficiency and effectiveness of providing universal standardized not-for-profit health coverage. American exceptionalism at its worst.

Has single payer reform definitively toppled? Amazingly, I’m not despondent with our chances. Instead, many factors favor its success. Public anxiety about access to (including affordability of) health care is higher than ever. Awareness of the structural failings of the system is pervasive. Pushback, e.g., against forced Medicare Advantage for union retirees, is rising. Political leaders in both parties are challenging private insurer abuses. Support for a central government role is inching up, with 2/3 support for Medicare for All, if the question is asked neutrally (“your taxes will rise, but you’ll no longer have premiums or cost-sharing, and you can choose your doctor”). Several states are actively pursuing major reform – single payer, or substantial steps on the path to single payer. There are federal bills. The leading candidate for president understands and has in the past supported single payer. Policy and advocacy experts are engaging with each other, as well as with elected officials and health agencies. I’m thrilled to be connected with these individuals and groups, doing all that I can with technical work like online household cost calculations and paths to slashing administrative waste (and, of course, with HJM).

There is a renewed determination to break the logjam, now that we clearly see the abject failure of “path dependence” – sticking with the approach started in World War II, when health insurance originated as an alternative to prohibited wage increases. We should have recognized long ago that the trajectory was off 
 since 1972, when the Nobel Prize in Economics went to Kenneth Arrow for showing that health care cannot work as a free market good. It’s not soybeans or mobile phones, it’s literally our lifeblood. Health care must be treated, as it is elsewhere around the globe, as a public good, to be disseminated, protected, and cultivated.

These times are fraught and exciting. The upcoming election is pivotal in US history: democracy, freedom, and community are at stake. Single payer is, likewise, resonant with American ideals of freedom (from worry and in choosing doctors) and, of course, community. The vitality we bring to the election and the vitality of health care reform efforts can, must, and will be reinforcing.

It’s hard to say when, but I see a tipping point ahead. I hope you do too. Stay the course.

https://healthjusticemonitor.org…

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Public Opinion on Health Reform

New polling in swing states on priorities for health care reform and related issues shows wide support for reducing the financial burdens of health care and for 
 wait 
 here it comes 
 Medicare for All.

Bernie Sanders: Democrats should run on a progressive economic agenda. Americans are ready., The Guardian, August 5, 2024

Bernie Sanders: In order to combat a political system which ignores so many of the most important concerns facing the majority of our people, my campaign recently commissioned a poll in the battleground states of Arizona, Georgia, Michigan, Nevada, Pennsylvania and Wisconsin. The results of the poll are not surprising, and not unlike other polls done over the years.

They show that, at a time of huge income and wealth inequality, unprecedented corporate greed, a failing healthcare system, a grossly unfair tax structure, an extremely high rate of childhood poverty, and too many seniors struggling to pay for their basic necessities, the American people want strong governmental action which addresses the longstanding needs of working families.

In other words, it turns out that progressive economic proposals are extremely popular – not only among Democrats but also among independents, Republicans and even the most ardent Trump supporters.

In fact, whether a candidate is running for the White House or a city council seat, endorsing policies that support working families is not only the right thing to do, it’s good politics.

Following are a few results from the detailed, 23-page poll:

Democrats have clear solutions for the biggest issues facing the country

  • 84% of Democrats agree
  • 9% of Republicans agree

Republicans have clear solutions for the biggest issues facing the country

  • 8% of Democrats agree
  • 88% of Republicans agree

Do you think large profitable corporations should pay more in taxes?

  • 88% of Democrats agree
  • 49% of Republicans agree

Do you think large profitable corporations should pay less in taxes?

  • 4% of Democrats agree
  • 15% of Republicans agree

Do you think the wealthy should pay more in taxes?

  • 89% of Democrats agree
  • 55% of Republicans agree

Do you think the wealthy should pay less in taxes?

  • 3% of Democrats agree
  • 9% of Republicans agree

Do you support or oppose establishing a Medicare for All single payer healthcare system?

  • 85% of Democrats support
  • 41% of Republicans support
  • 7% of Democrats oppose
  • 45% of Republicans oppose

Do you support or oppose cutting the cost of prescription drugs in half?

  • 89% of Democrats support
  • 79% of Republicans support
  • 8% of Democrats oppose
  • 13% of Republicans oppose

Do you support or oppose eliminating all medical debt?

  • 77% of Democrats support
  • 52% of Republicans support
  • 16% of Democrats oppose
  • 36% of Republicans oppose

For Third Year in a Row, PRI Survey Finds Vast Majority of Americans Are Satisfied with their Health Coverage, StreetInsider.com, August 5,2024

Based on a new national survey commissioned by Pacific Research Institute, a California-based, free market think tank, 91% said they were satisfied with their current health insurance plan.

Just 37% of respondents said they would support a complete government takeover of America’s health care system, where private health insurance would be banned, compared with 47% who were opposed.

Comment:

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

In this political season, it is imperative that we distinguish between the terms “policy” and “politics.” When policy concepts are totally removed from the political environment, the public, if they have a clear understanding of the policy, will generally choose what is right for them and not oppose what is right for the population as a whole as long as it does not have a significant negative impact on them. Although the intensity of the support for beneficial policies for others may vary based on political alignment, there is much more agreement in support of these beneficial policies than is commonly perceived. It is when special interest groups introduce more intense politics into the debate that deceptively larger differences in support will appear.

As an example, in health care, people support policies that make it universally accessible, with free choice of physicians and hospitals, making it efficient by eliminating administrative waste, eliminating barriers such as excessive cost sharing, or insurer prior authorization requirements, and, especially, making it affordable which can be most readily accomplished through progressive taxes, thereby eliminating the scourge of medical debt. As policies, these would all be widely accepted except for those concepts that have been tarnished by political attack, such as “taxes.” When these policies are combined, they would create the vastly superior single payer Medicare for All method of financing health care if it weren’t for the persistent political attack that has left part of our nation uncomfortable with the concept.

This bias in framing is evident in polling differences. Note the profoundly negative framing of the survey conducted by the right-wing Pacific Research Institute, asking about “complete government takeover of America’s health care system, where private health insurance would be banned” – employing frightening language, instead of highlighting the financial protections and health benefits of universal insurance. These framing debates will play out intensively in any attempt to win popular support for single payer, such as in ballot initiatives. We will see in the current presidential campaign if “joy” and shared responsibility for each other can win over doom-and-gloom government-is-your-enemy rhetoric.

Our more immediate task is to elect a President and a Congress that would be willing to enact and implement health policies (i.e., single payer) that would improve the cost, access and affordability of health care for everyone. For the next step we would need to intensify our education of the nation on precisely what these policies are, why they would be better for all of us, and then why we must change our politics and the rhetoric of our politicians so that the people would make it clear to the president and Congress that these are the policies (single payer) that they need to bring to us.

Education on policies will be the relatively easy part, but changing the politics so that we have a system to bring health to all of us instead of wealth to the select few will be the greatest task before us, but we have to do it.

https://healthjusticemonitor.org…

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Project 2025 Health Policy Critique Redux

Recap of three recent HJM detailed critiques of Project 2025 health policy proposals

The goal today is to provide maximally digestible and clarifying responses to this deeply problematic but often obscure agenda. There remains a fair amount of technical content. So, if you prefer, here’s a high-level summary:

The Project 2025 health policy roadmap is designed to increase the role of for-profit insurers, place a greater burden on individuals to pay for care, and cut public funding for health care for the poor, seniors, and the disabled. This will mean more medical debt and bankruptcies, less access to care, and worse health. The plan also targets abortion access, even where legal.

Or, more succinctly, perhaps social-media ready:

Project 2025 will weaken Medicare for seniors and people with disabilities, Medicaid for the poor, and private insurance for everyone. Insurance companies will do just fine, with a big boost to profits.

Private Health Insurance:

Project 2025: Promote direct primary care (DPC) by using health savings accounts (HSAs).

  • What it means: Pay DPC doctors via HSAs set up with high deductible insurance.
  • Why it’s bad: HSAs favor the healthy and wealthy, shifting unused funds to tax-free retirement accounts. This diverts money from health care to cushy retirements. (DPC itself is good: fosters continuity of the patient-doctor relationship and a focus on clinical care.)
  • What we need: Don’t let DPC serve as an excuse to shift more HSA health care money into the pockets of wealthy retirees. Single payer would provide everyone with insurance for primary care along the line of DPC (and specialists, and all other care), and would grow the primary care work force. Funds not used for primary care would go to other health care needs.

Project 2025: End Affordable Care Act (ACA) regulation of private health insurance.

  • What it means: Repeal ACA rules that: protect access to insurance (guaranteed issue); require community-rated premiums (sick individuals pay the same as everyone); assure broad benefits; and prohibit revoking insurance based on trivial errors when applying (recission). Also end restrictions on short-term insurance and health reimbursement / savings accounts.
  • Why it’s bad: ACA rules make private health insurance much fairer and dependable, by assuring reliable broad coverage without discriminating against individuals with pre-existing illness. Removing the rules would hurt everyone, especially the sick.
  • What we need: Single payer would provide identical, comprehensive health coverage to everyone, progressively financed. Meantime, keep private insurance effective and fair.

Project 2025: Use a “truth-in-advertising” approach to handle surprise medical bills.

  • What it means: Replace formal dispute resolution with an approach that relies on publicly stated prices.
  • Why it’s bad: The “No Surprises Act” payment resolution process has too much ambiguity and thus disputes. But “truth-in-advertising” won’t work: patients in emergency and high stakes medical situations can’t consider or act on complex price disclosures, and such disclosures will often be incorrect or misleading.
  • What we need: A system where all care is covered by the same insurance. You know, single payer. Meantime, refine the “No Surprises” process.

Project 2025: Adopt free-market methods like price transparency and shared savings.

  • What it means: Rely on providers to post prices and on patients to choose cheaper options (and share in the savings).
  • Why it’s bad: Neither works. Most hospitals don’t comply with current price disclosure rules, and the posted lists are so complicated as to be unusable by consumers – far too many procedures and variants, price elements, and health plans. On the patient side, higher prices are seen (incorrectly) as a marker of higher quality, which everyone demands when it comes to medical care. “Skin in the game” strategies don’t control health care costs. Indeed, medical care can not work as a “free market” (Ken Arrow, 1972 Nobel Prize in Economics)
  • What we need: Proven ways to reduce health care costs – eliminate our massive and massively expensive billing and insurance-related administrative bloat. Negotiate drug and equipment prices. Adopt global budgets.

Medicaid:

The proposed changes, despite being couched in bureaucratic buzzwords, have a straightforward and nefarious intent: Reduce health insurance coverage for the poor, by restricting both eligibility and benefits. And, equally worrisome, use Medicaid to suppress access to abortion.

I’m committed to making the phrase “medical insurance for the poor” archaic, by covering everyone well under one system. Meantime, let’s keep this insurance generous.

Project 2025: Reform Medicaid funding with “balanced” match rates, block grants, and caps.

  • What it means: “Balanced” federal-state funding means that Medicaid would get less federal money (now 65% of the total). “Block grants” and “caps” mean fixed funding, regardless of the size of eligible populations and their medical needs, and slow or no growth over time.
  • Why it’s bad: This deprives our main health insurance for the poor – already underfunded – of important resources.
  • What we need: Keep Medicaid robustly funded. Indeed, increase as we did during the COVID pandemic. And end the idea of “health insurance for the poor” – with single payer for all.

Project 2025: Improve Medicaid eligibility standards to protect those in need.

  • What it means: Cover only the very poorest and sickest, leaving out many who currently qualify and Who, in today’s fragile health insurance environment, meaningfully benefit from Medicaid.
  • Why it’s bad: The financially and medically *merely* needy – but not in desperate straits – go without insurance and thus with major financial barriers to care.
  • What we need: Keep Medicaid eligibility so that it reaches all the needy, kindly defined. With single payer, everyone would be covered.

Project 2025: Incentivize personal responsibility: require work & match benefits to individual needs.

  • What it means: Impose preconditions on program eligibility, and limit coverage to the minimum necessary given financial status and medical need.
  • Why it’s bad: Work requirements fail – they don’t increase work rates, but do kick people off Medicaid and thus impair access. Limiting coverage is complex, conjectural, and stingy – assuring that tens of millions of beneficiaries will experience significant barriers to care.
  • What we need: Keep Medicaid eligibility so that it reaches all the needy, reasonably defined. With single payer, everyone would be covered.

Project 2025: Allow Medicaid to contribute to flexible private insurance accounts for families.

  • What it means: Medicaid money can be used to support health savings accounts instead of public insurance.
  • Why it’s bad: This represents shifting already inadequate public insurance funds to an approach that benefits private insurers and families with fewer medical needs. This will further weaken the Medicaid mission to protect the poor and sick. It endorses a skin-in-the-game market approach that, as noted elsewhere in this post, does not work.
  • What we need: Sustain the Medicaid mission to pay for health care for the poor, especially those with greatest medical needs. Once again 
 with single payer, public funds would pay for health care according to medical need.

Project 2025: Redesign eligibility, financing, and service delivery of long-term care.

  • What it means: I admit, I’m confused. It elaborates a reasonable sounding goal: “serve the most vulnerable and truly needy and eliminate middle-income to upper-income Medicaid recipients.” Except that, to qualify for Medicaid support for long-term care, there are already strict income and wealth criteria, which work to focus efforts on the needy (although admittedly with gaming by some families).
  • Why it’s bad: It would be fine to reduce gaming, so that resources are not diverted to families who don’t need them. However, I worry that this serves as a pretext to limit eligibility to the poorest of the poor, impoverishing individuals and spouses.
  • What we need: Maintain the long-term care benefit. Under single payer, long-term care is an affordable and essential benefit.

Project 2025: No funding for providers that conduct abortions, and severe financial penalties for states that pay for abortions.

  • What it means: To be clear, this is not refusing to use Medicaid funds to pay for abortion; that’s already in place. This is about penalizing providers and states that in any way support access to abortion.
  • Why it’s bad: It’s punitive, and contradicts the Right’s supposed deference to states on abortion issues. Thus it further compromises abortion rights, beyond the Supreme Court’s Dobbs reversal of Roe v. Wade.
  • What we need: Federal funds should not be used to penalize states that permit abortion. Single payer would pay for abortion where legal, and IMO that should be everywhere.

Medicare:

Project 2025 proposals focus on increasing the role of private insurers and market solutions. Both, we’ve seen, fail. This approach increases prices, enabling massive financial gains for corporate executives and shareholders.

Project 2025: Increase beneficiary control of care via information about providers & insurance.

  • What it means: Make it the patient’s responsibility to review and interpret complex information about provider quality and prices.
  • Why it’s bad: Choice of provider, yes! However, it’s a debunked myth that valuing health care is like valuing cars or phones. Health care is complex and often emotionally fraught. It’s unsuited for this free market approach.
  • What we need: Let’s stop pretending that a “free market” can fix health insurance. Under single payer, everyone would have free choice of providers, fully paid for, and quality improvement would be a program priority.

Project 2025: Rely on intermediate entities to control costs and improve quality. Make Medicare Advantage the default plan.

  • What it means: Medicare Advantage private insurance plans and traditional Medicare ACOs & direct contracting entities should operate between beneficiaries and providers.
  • Why it’s bad: It’s not working, quite the opposite. Medicare Advantage results in >$100 billion in excess spending each year, and huge profits for insurers, while beneficiaries often can’t afford care. ACOs don’t control costs. Neither improves quality.
  • What we need: Let’s strengthen traditional Medicare by reducing cost-sharing (such as lowering drug prices) and rein in Medicare Advantage abuses. Single payer uses direct funder to provider approaches, with no intermediary profits, shown to work in 32 wealthy nations.

Project 2025: Shift to value-based payments, within traditional Medicare.

  • What it means: Use VBPs of various types to control costs and raise quality.
  • Why it’s bad: Value-based payment is a loosely defined idea that financial incentives should foster efficiency in selection and implementation of care. This works for many goods and services, but not for health care – which for patients is driven by pressing need, and for providers is driven by technical expertise and a desire to heal. Health care is not widgets. ACOs, the premier VBP model, failed to achieve goals. VBP is misplaced in health care and distracting.
  • What we need: Medicare should pay for care, and abandon the failed experiment with VBP. Under single payer, costs are controlled with administrative efficiency, price negotiations, and global budgets; quality is enhanced through research, training, and oversight.

Project 2025: End drug price negotiations; lower the Medicare role for catastrophic drug costs.

  • What it means: Terminate or subvert the drug price negotiations created by the Inflation Reduction Act. Reduce the program portion (thus raising beneficiary burden) when drug costs accelerate.
  • Why it’s bad: The IRA provides baby steps toward the much-needed and widely-used (in other nations) drug price negotiations. Pharma can well afford prices that align better with global levels. And it’s especially cruel to abandon beneficiaries when costs are highest.
  • What we need: Continue to implement and expand drug price negotiations in Medicare. Under single payer, as around the world, that’s how the system assures affordability while allowing solid Pharma profits.

https://healthjusticemonitor.org…

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Cost-Sharing, Coverage Denials, Missed Care, & Medical Debt

The Commonwealth Fund, a respected monitor of US health system performance, highlights how cost-sharing and coverage denials lead to widespread missed care and medical debt. The system is unfair and opaque. Administrative tweaks won’t resolve these problems for private insurance designed to benefit executives and shareholders at the expense of patients.

Unforeseen Health Care Bills and Coverage Denials by Health Insurers in the U.S., The Commonwealth Fund, August 1, 2024, by Avni Gupta, et al.

Americans are increasingly struggling to get their health insurance to work for them. High deductibles and copayments are causing nearly two of five working-age adults to delay visiting the doctor and filling prescriptions. Those who do get care can become burdened by medical or dental debt, something almost one-third of working-age adults report experiencing. Billing errors and denials of coverage by insurance companies may contribute to this problem. Media investigations have found that insurers are becoming increasingly adept in using technology to deny payment of medical claims and pressures their company physicians to deny care during prior authorization reviews. Doctors also report spending increasing amounts of time on the phone with insurance company physicians over denials of care for their patients.

In this brief, we report findings from a Commonwealth Fund survey on the extent to which working-age adults say their insurance provider charged for a health service they thought should have been free or covered or denied coverage for care recommended by their doctors. We examined whether people challenged such errors or coverage denials, the reasons why they didn’t, and the implications for their health and well-being.

From the Discussion:

The complexity of the health insurance system in the United States has left many people struggling to understand what services are and aren’t covered and their financial liabilities when they get care. On top of this complexity, insurers are motivated to avoid paying for care. Many insurers appear to be utilizing increasingly aggressive tactics to do so, deploying technology and applying pressure to company physicians to scrutinize services recommended by patients’ physicians and often to deny coverage, leaving patients with unexpected bills or delays in care.

When looking at people’s billing disputes and denials of coverage, what emerges is that many realize positive outcomes when they appeal decisions they perceive to be in error. Yet only half of those who believe they were erroneously billed or denied care actually challenged the decision or had a doctor challenge it on their behalf. The survey shows considerable consumer confusion among patients and their families about their right to appeal and who to contact. The responsibility of appealing may not be clear between patients and providers, or between employers and employees, and the documentation requirements to appeal can create additional barriers. The current system with its complicated appeals processes can be detrimental to patients who are most in need of services.

Comment:

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

Americans often do not understand why, when we have the most expensive healthcare system in the world, so many people are left without the care they need, and are saddled with excessive medical debt for services that common sense would indicate insurance should cover. The answer is, simply, the system was designed to provide increased revenue and profits for insurers and other intermediaries by increasing administrative services, which often oppose the interests of patients – thus diverting funds from medical care to executives and investors.

If you read the full report, you will find that suggested corrections to the problem are primarily in adjusting administrative functions. This misses the big picture: Protecting superfluous administrative functions by adding even more administrative functions, supervised by an industry that thrives on (and is adept at) drawing off patient care funds, hardly seems like a satisfactory solution to the problems of inadequate patient care in an environment of rising medical debt.

Of course, we know what the answer is: a single payer financing system. We need to provide comprehensive health care to everyone, and fund the system with progressive taxes that everyone can afford. Administrative functions would be drastically simplified, and directed to making health care accessible for all and paying for it without rewarding a superfluous industry that is designed primarily to create wealth rather than preserve health.

https://healthjusticemonitor.org…

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Building power nationally for health justice

Interview with Dr. Ed Weisbart

Building Bridges, WBAI Pacifica Radio, August 5, 2024

PNHP national board secretary Dr. Ed Weisbart discusses his recent piece in Common Dreams, “To Win ‘Medicare for All,’ First Reclaim Medicare From Profiteers.”

Dr. Weisbart cites the corporate insurance industry’s indefensible overcharging of taxpayers—to the tune of up to $140 billion per year.

“If we could get that money back from them,” he says, “then we could use that money to help us pay for hearing, and vision, and dentistry for everybody in Medicare” along with other important health care priorities.

https://wbai.org


How Harris Left Medicare For All Behind

Kamala Harris once championed a true universal health care plan, only to walk it back. Now, nobody knows where she stands.

By Amos Barshad
The Lever, August 2, 2024

On a chilly Monday night in January 2019, Kamala Harris was in Des Moines, Iowa for a CNN town hall. At the time, Harris was the junior senator from California and one of nearly 30 candidates vying to be the Democrats’ 2020 presidential nominee. A few minutes into the event, a self-employed local resident named Renee Welk asked a pertinent, inevitable question: “What is your solution to ensure that people have access to quality health care at an affordable price?”

Without hesitation, Harris answered, “We need to have Medicare For All.” Then, as the applause rang out, she riffed beautifully. “To live in a civil society, to be true to the ideals and the spirit of who we say we are as a country,” Harris said, “we have to appreciate and understand that access to health care” is not a “privilege” but a “right.”

“It is inhumane,” she continued, “to make people go through a system where they cannot literally receive the benefit of what medical science can offer because some insurance company has decided it doesn’t meet their bottom line in terms of their profit motivation. That is inhumane.”

This wasn’t Harris’s first time publicly backing universal government-sponsored health care: In 2017, she was one of the first co-sponsors of Sen. Bernie Sanders’ (I-Vt.) sweeping Medicare For All bill. But never before Des Moines had Harris spoken about the issue so forcefully, so passionately, and under such a bright spotlight.

When CNN’s moderator Jake Tapper pushed her on whether that meant she would “eliminate private insurance,” Harris seemingly stayed resolute. She described the painful process of filing an insurance claim, of dealing with all of the required paperwork, of facing delays in coverage, and then said: “Let’s eliminate all of that. Let’s move on.”

For supporters of universal health care, it was a stirring moment, a rousing defense from a senator whose state was then in the early stages of its ongoing fight for a single-payer system. For Harris, fighting to make herself known nationally, it was potentially definitive. On an issue of grave importance, she had spoken with a ringing moral clarity.

But within days, as opponents across the political spectrum launched attacks on her position, Harris and her campaign began walking it all back.

In confused, mealy-mouthed statements, campaign reps told the media that while Harris’s “preference” was Medicare For All, she was open to more than one “path” to providing universal coverage. By the summer of 2019, Harris had proposed a widely panned proposal that critics said would continue to enrich the private insurers who have fueled the country’s health care crisis.

Now that Harris is the Democratic Party’s presumptive 2024 presidential nominee, questions about her back-pedaling on Medicare For All have a new urgency. What does her retreat under pressure from powerful monied interests tell us about a potential Harris presidency’s agenda on issues that conflict with donors’ demands?

Medicare Privatization For All?

Throughout 2019, Harris stumbled repeatedly when prompted to express her views on Medicare For All. In May 2019, in another interview with CNN’s Tapper, Harris said that back in Iowa, when he’d asked her if she wanted to get rid of insurance companies and she said yes, that was actually “not what I meant.”

During a debate in June of that year, when the candidates were asked who would be in favor of eliminating all private health care insurance, Harris raised her hand. Days later, she again backed off the position. The next month, in a Medium post headlined “My Plan For Medicare For All,” Harris finally released the specifics of her health care plan.

“She called it Medicare For All,” said Adam Gaffney, an ICU doctor and the former president of the advocacy group, Physicians for a National Health Program. “But it really wasn’t. She did envision covering everyone and that is laudable and that is critical. But the plan maintained a central role for private insurers, and we’ve seen year after year is that private insurers are driving up the cost of care. They are a key problem in our crisis.”

Medicare For All is also known as single-payer health insurance because it would create one federal government entity that would oversee all health care spending. Its advocates believe the best way to provide health insurance to all Americans is by improving and expanding Medicare, a system that has successfully provided health care for millions of people for decades. Advocates also estimate a single-payer system would net $500 billion in savings by mimicking the efficiency of Medicare, which spends just two percent of costs on administrative tasks like billing.

Harris’s plan wasn’t a single-payer system. Instead, it aimed to give all Americans the choice of enrolling in Medicare while also likely expanding Medicare Advantage, the controversial for-profit insurance program subsidized by the federal government.

People choose Medicare Advantage because it’s cheap: The upfront premiums average less than $20 a month. What they don’t know is that actually receiving treatment with their Medicare Advantage plan is costly in other ways: Critics say that Medicare Advantage insurers profit by denying patients care.

The Journal of Clinical Oncology has found that, in part due to inferior care options, cancer patients in Medicare Advantage have higher mortality rates immediately after surgeries than traditional Medicare enrollees. Researchers studying one large insurer’s data found a 15 year increase in denials over a five year period. One in three Medicare Advantage enrollees are denied at least one claim annually. The programs are being investigated by the Department of Justice for fraud.

This privatized version of Medicare has existed in previous versions since at least the nineties. In 2003, it was renamed Medicare Advantage. Under Trump, it ballooned. In 2018, his administration’s Department of Health and Human Services sent physical letters to millions of Americans saying things like “See if you can save money with Medicare Advantage.” Under the Biden and Harris administration, its growth continued. Last year, around half of all eligible patients were in Medicare Advantage plans rather than traditional Medicare.

As The American Prospect wrote in 2019, “what’s so insidious about Harris’ approach” is that it “would expand the commercial part of the system, falsely branded as a variant of Medicare, and take us further away from true seamless and universal coverage.” While that’s not good for patients, it’s also not good for the federal budget. As The Lever recently reported, “The federal government is losing as much as $140 billion per year by subsidizing private Medicare Advantage plans.”

As far as the GOP is concerned, Medicare Advantage should get even bigger. Project 2025, a broad package of policy proposals being pushed by the Heritage Foundation as the blueprint for a second Trump administration, wants to set Medicare Advantage as “the default enrollment option” for Medicare.

It’s been fourteen years since the Obama administration passed the Affordable Care Act and in many ways America’s health care crisis is worse than ever, as health insurance companies have taken advantage of its many loopholes. This year, the prices of health insurance premiums are estimated to reach record highs. By 2026, the number of uninsured Americans is predicted to spike to over 30 million.

By the end of 2019, in the wake of her flailing around Medicare For All, and as her support waned, Harris quit the Democratic primaries.

In the summer of 2020, Joe Biden — who, during his own successful campaign for the Democratic nomination, explicitly said he’d veto any Medicare For All bill as president — named Harris his vice president.

How Harris “Abandoned” Medicare For All

When Harris first began talking about her support for Medicare For All, she often told the story of her own mother who died in 2009 at 70 years old, due to complications from colon cancer. In a 2018 New York Times op-ed, Harris wrote touchingly of cooking “elaborate meals for her, filling the house with the smells of childhood,” and of finding time outside of her then-job as San Francisco district attorney to hold her mother’s hand “through the misery of chemotherapy.” She wrote, “I am so grateful my mother had Medicare, and I will fight for it to be guaranteed to all.”

In the fall of 2019, Harris sat down for an interview with Ady Barkan, the Medicare For All advocate who died last year, at the age of 39, from complications of ALS. At that point, Harris had already released her Medicare Advantage-boosting health care plan.

At first, the two speak in generalities about the importance of health care over the kind of crescendoing instrumentals that would sound right on a motivational YouTube sports highlights compilation. Barkan asks Harris about her late mother; Harris breaks down in tears. Then, to his credit, Barkan doesn’t let the opportunity slip to push back on the specifics of Harris’s plan.

“You philosophically believe the insurance companies play a useful role and should continue existing?” he asks her, using the augmentative technological intervention he needed to communicate toward the end of his battle with serious degenerative disease.

“I believe that those who abuse the system should be held accountable, but I am not trying to get rid of all private insurance,” she answers. “The problem is they have been writing the rules and they have been taking advantage of consumers.”

Michael Lighty, a longtime Medicare For All advocate, worked as the health care constituency director for Sen. Sanders’ 2020 presidential campaign. He was also the longtime single-payer expert for the California Nurses Association/National Nurses Union organization, which represents over 150,000 nurses nationwide.

He recalls being initially impressed with Harris’s thoughts on Medicare For All, both during the Des Moines event and on previous occasions, “It was very passionate, very sincere. Her framing was ‘we’re not getting a good ROI on health care,’ which was certainly unique, but she definitely seemed committed to the issue.”

The context for Harris’s eventual retreat, Lighty said, was that support for Medicare For All was making the Sanders campaign a target for huge attack ad spending. “Bernie was getting hit with about a million-and-a-half dollars in Iowa” ahead of the 2020 caucus, Lighty says. Meanwhile Pete Buttgieg, then best known as the former Mayor of South Bend, Indiana, “was claiming he had a better plan, some kind of public/private combination.” Sen. Ellizabeth Warren (D-Mass.) “felt compelled to prove how we pay for it in order to distinguish herself, which was not a smart move politically,” Lighty said. “You don’t wanna talk about what it’s gonna cost you, you wanna talk about what it’s gonna save.”

Harris, he explained, was trying to find something to make herself stick out while avoiding the ad spending being directed against Sanders for his support of Medicare For All.

“A majority of voters want the option to keep their plans,” Lighty said. “Primarily that’s because the situation is so bad, they’re desperate to keep what they have.” Political consultants “will tell candidates, ‘you don’t want to be out there telling people you’re taking away their plans.”’

When Harris finally did release her so-called version of Medicare For All, Lighty explained, she “backed off the fundamental principle — a single, publicly-administered plan that would eliminate the power of the commercial insurance companies.” For the Sanders campaign, Lighty says, Harris’s plan felt like an opportunity. “So, fine. Not ‘fine’ from a policy perspective, because she’s wrong.” But it distinguished Sanders as the sole champion for a true Medicare For All proposal.

“She had abandoned support for Medicare For All,” Lighty concluded. “We saw it as exactly that.”

In the long fight for universal healthcare, 2019 was “a very exciting time,” said Gaffney, the ICU doctor. “Single-payer activism had been going on for decades, but for many years had really been on the sidelines” of the political discourse.

Sanders’ 2016 presidential run energized the issue; with the ongoing efforts of progressive activists, and the broader pushback to the Trump administration, Medicare For All suddenly had real momentum. And Harris in Des Moines was a significant moment in the groundswell.

But despite bipartisan support, the movement faltered. “I think many politicians responded to the energy of their progressive constituencies,” Gaffney said. “But it’s one thing to sign on. It’s another thing to stay on.”

“I’ve Never Encountered Kamala”

Alex Lawson is the executive director of the advocacy organization Social Security Works, which aims to expand Social Security and Medicare. He’s an advocate for Medicare For All and has helped draft single-payer legislation introduced in the House of Representatives.

Of the plan Harris proposed in 2019, he said, “I totally reject the idea that the policy is terrible.” He understands why people might be alarmed at the plan’s potential to expand Medicare Advantage. But he said, “Harris’s goal is really clear. It’s to not allow corporate insurers to delay and deny care.”

He doesn’t agree with the people criticizing her approach as an expansion of Medicare Advantage, saying that was not her intention: ”I can tell you, I was right there.” As an activist in close communication with both the Sanders and the Harris teams, he saw that “Harris and her staff were looking to guarantee health care for Americans.’”

In her 2019 proposal, Harris writes, “Essentially, we would allow private insurance to offer a plan in the Medicare system, but they will be subject to strict requirements to ensure it lowers costs and expands services. If they want to play by our rules, they can be in the system. If not, they have to get out.”

Lawson points to the Biden-Harris administration’s health care track record, which includes, he says, “the largest expansion of Medicare since the creation of Medicare,” and the creation of price caps on a select handful of drugs for Medicare patients. Harris should be judged on what her administration has done, Lawson argued: “They beat pharma! The unbeatable pharma!”

For Lawson, Harris’s walkback on Medicare For All in 2019 is not as telling as its critics believe it to be. “That episode is not nearly as clarifying as the totality of what she did before, during, and up to now,” he said.

As President, Biden was very cozy with the insurance industry: He welcomed its lobbyists to his very first fundraisers, and he took its cues when crafting emergency relief policies during the pandemic.

What kind of relationship Harris will look to build with insurers is not yet known. According to Open Secrets, Harris now has over $800,000 in donations from the health services sector, which includes insurance giants like UnitedHealth and Blue Cross Blue Shield. (Donations to Biden’s campaign before he dropped out will now be transferred to Harris’s campaign, and so are included in that number.)

The Harris campaign recently told The New York Times that Harris “no longer supported a single-payer health insurance program.”  In a statement to NBC News on July 31, a campaign official said, “The VP will not push single payer as president.” When reached for comment, a Harris campaign official confirmed that to The Lever, adding, “The VP won’t push her 2019 health care plan. She will continue to build on the successes of the Biden-Harris Administration — lowering prescription drug costs and making health care more affordable and accessible.” The campaign official declined to elucidate Harris’s vision any further than that.

On July 30 of this year, Harris commemorated the anniversary of the creation of Medicare, signed into law by Lyndon B. Johnson 59 years ago, with a post on X, formerly Twitter: “Trump’s Project 2025 plans to cut Medicare and roll back our progress on Medicaid. As Vice President, I have worked to expand these programs—and we are not going back.” Once, she was clear and bold on the issue; these days, she is a cipher.

RoseAnn DeMoro, the former executive director of National Nurses United, is widely known as one of the most effective union leaders in recent American history. Before retiring in 2018, she helped create real and ongoing momentum for single-payer health care in California and remains an activist for Medicare For All in the state and nationwide. When asked about Harris’s shifting positions on Medicare For All, she first offers a preamble: “I really want her to win, and I hope you say that. She has to win.”

Then she said of her former neighbor in the Golden State, “I’ve been in the political world forever. And I cannot tell you what she advocates. In all my years doing political work in California, in terms of our issues, I’ve never encountered Kamala.”

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