PNHP

Medicare’s disadvantage

Medicare’s disadvantage

By Kenneth Dolkart, M.D.
Valley News (West Lebanon, N.H.), Letters, June 17, 2024

Lake Sunapee VNA & Hospice CEO Jim Culhane shared how unacceptably low reimbursement by United Healthcare threatens essential services by community visiting nurses (“For-profit companies use Medicare as a lever”; June 11). He notes how seniors face harmful denial of services, limited inpatient rehab and restrictions to narrow medical networks and unexpected discontinuation of coverage for medications. These measures maximize profit, but harm patients.

There is a “bait, then can’t switch” feature: the initial guarantee to purchase affordable Medigap insurance disappears after a year’s enrollment with Medicare Advantage. Supplementary policies are thereafter denied or unaffordable for those who try to switch. Since 20% of traditional Medicare costs are covered by Medigap, many are financially trapped in a plan they don’t want. So much for the “consumer choice” touted by ads. Four states do preserve “guaranteed issue” but this can raise premiums, since higher costs of ill seniors are passed back from Medicare Advantage to traditional Medicare and Medigap plans. Of course, since the plans are all owned by the same corporations, that’s a win-win for Wall Street!

Medicare Advantage proposed to expand benefits and use managed care “efficiencies” to save Medicare money. In reality, Medicare pays privatized plans 22% more per beneficiary than traditional Medicare expended for identical services, despite their enrollees being healthier. Such “efficiencies” cost $104 billion to taxpayers. These excessive capitations to for-profit intermediaries offers a tax-funded Medicare Advantage gravy train. $100 billion is better spent improving long-term and home care, dental or vision benefits under traditional Medicare, with lower administrative costs and burden for hospitals and clinicians.

https://www.vnews.com…

Time, Supply, and Single Payer

Expanding the supply of health care to increase competition will not control costs or cure our health system woes. Health care is unlike other economic markets. The solution is need-based expansion and efficient use of capacity to meet medical needs. Single payer and public ownership offer the tools.

Supply-Side Healthcare?, Phenomenal World, May 9, 2025, by Adam Gaffney

The politics of hospital care and construction

As some pundits tell it … “supply-side” competition-based expansion is exactly the medicine our healthcare system needs. The root cause of constrained access and rising healthcare costs, the argument goes, is public regulation giving the provider side of the market more leverage, allowing it to extract higher payments from insurers. Greater competition will lead to expanding supply, leveling the playing field between providers and insurers without altering the nature of ownership or public responsibility in the sector. “Call it supply-side economics, but for healthcare,” Matthew Yglesias wrote in Bloomberg, advising that we “focus less on the way insurance works than on expanding care to increase competition and reduce prices.” The Nikansen Center echoes the sentiment and generalizes it across those service industries at the core of American life. In healthcare, higher education and housing, this bipartisan consensus argues, supply expansion is the solution to rising costs.

Hospital supply expansion surely is needed in many places in the United States; decades of disadvantage, discrimination, and disinvestment have left many communities—particularly those with low-income and minority populations—deprived of needed healthcare facilities and resources. The problem is that the new “supply-side” gambit won’t succeed in securing access to healthcare for these populations. Nothing in the existing marketplace ensures that new construction will go where it’s needed. All evidence suggests that it will, rather, be put in the service of gaining market share in already lucrative areas. …

“Supply-side economics, but for healthcare” misdiagnoses the basic problem, which is not the performance of competition but rather the nature of financing and ownership. US hospitals are increasingly dominated by corporate behemoths and private equity firms who usher in skyrocketing prices and inequities while degrading the quality of care. Any effort to expand supply within the existing US healthcare scene will only accelerate this galloping corporate takeover, making us worse off in the process. Moreover, the nature of healthcare—a service with unique characteristics distinct from other commodities—poses profound consequences for the supply-side strategy of harnessing entrepreneurial spirits to expand provision efficiently. Unlike other services, the supply of healthcare induces its own demand, for every human body ultimately fails. Hospital beds, doctors’ hours, and machines can generally be put to some use. …

Multiple recent econometric analyses have found that when a shift of demand affects the use of care by one population—for instance, due to gain (or loss) of insurance coverage—the change in utilization of care by that population tends to be offset by slightly less (or more) care provided to populations whose coverage does not change. … My research with colleagues has come to similar conclusions. We analyzed health survey microdata before and after implementation of Medicare in 1966 and the Affordable Care Act in 2014, finding little evidence for an aggregate increase in society-wide healthcare use despite a substantial expansion of insurance (i.e. of demand), with some redistribution in use towards newly insured populations. Reviewing published utilization effects of some thirteen universal coverage expansions in capitalist nations over the past century, we found generally similar trends. …

Comment:

By Adam Gaffney, M.D., M.P.H.

As single-payer advocates, much of our focus is on healthcare access, particularly cost barriers stemming from uninsurance and underinsurance. That stands to reason: most of us fight for a better healthcare system primarily because we want to see everyone get the high-quality medical care they need when they need it. We care, more than anything, about health. Single-payer would mean that our demand for care (in economist-speak) would depend not on our insurance or wealth, but rather on our medical needs — it would, that is to say, expand and equalize “demand” by removing cost barriers that suppress use of care for the less fortunate.

But how we think about healthcare supply is important as well. Some conservative and even liberal thinkers argue that rather than focus on expanding coverage (i.e. demand), we should expand supply: i.e. more clinicians, more hospitals, and so forth, and thereby drive down the cost of care by fostering market competition. This article (by me) begins as an exploration of these “supply-wide” proposals, and argues that they wouldn’t accomplish what proponents think they would — indeed, they would cause costs to rise. It ends by making a broader argument about how the essence of medical care is time spent by human beings — time that can be redistributed but not expanded.

Supply expansion would fail as a cost control measure — even if it is needed for some services, like primary care, or for disadvantaged communities that have been left behind in our system — for a variety of reasons, as I trace, including the inefficiencies and redundancies that competition generates. Additionally, in medicine, supply often creates its own demand: ICU beds tend to be used when available, and our clinic schedules can invariably be filled.

That being said, some also envision a world where a supply-side transformation — e.g. from technological advances like AI – reduces the labor inputs needed to provide care (and other services). But in healthcare, I argue, there is zero historical or theoretical reason to believe that this will happen. Indeed, over the last century, as healthcare has been more capital intensive it has also in a sense become more labor intensive. There are more dollars of physical hospital capital assets per hospital bed than ever before, even as the number of nursing FTEs per hospital bed day has risen with the rising technological complexity of care, to give one example. On a more fundamental level, even with new tools and technologies, the time we need as healthcare providers to interview patients, evaluate reems of data, respond to concerns and questions, advocate for services, and formulate treatment plans will not fall — if anything, it will only rise. There will be no magical technological productivity fix to our healthcare woes.

We do need supply-side changes, to be clear, just not the ones that neoliberals envision. As healthcare delivery is gobbled up by corporations, cost and waste will rise even as quality deteriorates; we should think about public and community healthcare ownership along with public financing. Moreover, the simplicities of single-payer financing allow for major reductions in administrative costs, shaving off hundreds of billions of unproductive healthcare spending annually, as advocates frequently note.

At the same time, though, we should recognize that the value of some things we need, and healthcare is a prime example, is very much tied to the time that a human being puts into them. Versions of these services that contain less time – shorter visit lengths or higher patient to nurse ratios in the hospital – often have less fundamental value. Less time is being devoted to our care and health. Such time cannot be manufactured like commodities, it can only be more fairly distributed in society.

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.

Medicare for All Explained Podcast: Episode 112

The Harm Caused by Medicare Advantage

June 15, 2024

Podcast host Joe Sparks highlights PNHP’s latest report, “Taking Advantage: How Corporate Health Insurers Harm America’s Seniors.”

He cites the many ways that so-called “Medicare Advantage” plans harm seniors—from narrow networks, to high costs, to an increased likelihood of death for certain cancer patients—and reminds us that improved Medicare for All would dramatically improve matters.

Additional episodes will be uploaded monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Medical Debt, U.S. Pandemic

Medical debt is widespread in the US. This video reviews causes and consequences. And considers solutions. Single payer would end medical debt.

The State of Medical Debt in the U.S., (2-hour video with ten experts), Lown Institute, May 20, 2024, Website article by Noelle Serino

Medical debt has reached epidemic levels in the United States, impacting millions of Americans and creating barriers to good health. “This is a mammoth problem that is seriously impairing the mental health, the physical health, and the productivity of our country”, said Dr. Vikas Saini, President of the Lown Institute.

“We need to enact some sort of universal, publicly-funded national single-payer plan that is administered at the state and local levels with comprehensive, lifetime benefits, dental, vision, mental health care, and so forth” said Berneta Haynes, Senior Attorney, National Consumer Law Center.

The link provides access to a two-hour video of a panel of experts covering the topics of 1) scope of the problem, 2) drivers of medical debt, 3) insights from new research, and 4) opportunities and challenges for change.

Comment:

By Don McCanne, M.D.

Our nation continues to demonstrate how our reliance on private health insurance has been a mistake, especially when considering the financial burden that it places on lower-income individuals. For national statistics on medical debt prevalence and consequences, see here and other HJM posts.

What is difficult to understand is that we know that adoption of a national single payer program would not only prevent such financial hardships, but it would also ensure affordable access to a high-performance health care delivery system for absolutely everyone.

What on earth is preventing us from moving forward with the enactment and implementation of such a program? We certainly have the supporting data, but where is our will?

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.

Stop for-profit insurers from taking over our health care

By Aija Nemer-Aanerud and Rose Roach
Minnesota Reformer, June 12, 2024

No one’s health should be held hostage by private companies that reward investors with the money we pay for care. Yet that’s exactly what UnitedHealth Group and other for-profit insurers do every day, all across the country. And they will keep doing it until we stop them.

Private insurers deny and delay care to hundreds of millions of policyholders every year. Why? To boost profits. They force people like you and me to wait or die while their executives and shareholders get rich. They’d rather pay penalties than pay for care when doctors say we need it.

That’s why we celebrate Minnesota Democratic-Farmer-Labor lawmakers’ recent vote to ban for-profit insurers from offering HMO policies through Medicaid and the State Employee Group Insurance Program. This bold move sets an example for the nation and partially restores Minnesota’s longstanding ban on for-profit HMOs.

As long as we allow private insurers to find new ways to extract profits from health care, they will. Minnesota should lead the nation, and fully ban for-profit insurers from the state.

Minnesotans have long agreed that for-profit insurers should never be allowed to decide whether we live or die. That’s why, for 40 years, we banned for-profit HMOs from offering policies here. Then in 2017, the Republican-controlled Legislature allowed for-profit health insurance corporations to offer HMO services under the guise that doing so would benefit patients, even though they would have to charge more or deliver less services to meet their legal obligation to maximize profit for their shareholders. Private, for-profit companies like UnitedHealth, Humana and Aetna have been chomping at the bit to expand their involvement in Minnesota’s public programs like they’ve already done with Medicare Advantage.

From Minnesota-based UnitedHealth to Connecticut-based Aetna and other large insurers across the country, Medicare Advantage and Medicaid managed care programs have proven to be huge profit centers for health insurers, which is why they want to expand into Minnesota’s public health programs as well.

The U.S. Department of Labor sued a UnitedHealth subsidiary last July for wrongfully denying thousands of claims, and they were sued again in November for using faulty artificial intelligence to deny coverage for Medicare patients. They use data analytics to cut reimbursements to the bone, which helps UnitedHealth keep an extra $1 billion in fees every year, according to reporting in the New York Times. Then they sue policyholders — Allina even created a subsidiary to go after its own members.

Who gets hurt when private insurers deny claims? We all do. Doctors, nurses and people who need care are all increasingly fed up. That’s why we recently risked arrest in a peaceful protest at UnitedHealth’s headquarters to demand they stop these denials of care, along with People’s Action members who came from all across the country and allies from the Minnesota Nurses Association, the AFL-CIO Retirees, Physicians for a National Health Plan, Healthcare for All Minnesota, Be A Hero and the Labor Campaign for Single Payer. We then confronted UnitedHealth’s CEO — Sir Andrew Witty — on Capitol Hill, where he was called to testify to Congress about a data breach at a UnitedHealth subsidiary, Change Healthcare, which violated the personal data of as many as 152 million people.

This outage disrupted care for patients at 74% of hospitals nationwide, as many providers were forced to stop processing or switch to paper claims, which can take six months to approve. For Witty and UnitedHealth, this disruption was just another day at the office — one more opportunity to collect premiums while they delay and deny care.

Minnesota Attorney General Keith Ellison was right to oppose UnitedHealth’s takeover of Change Healthcare in 2022, recognizing the risks to our health if we allow private insurers to become “too big to fail.” Private insurers like UnitedHealth, which took in $22.3 billion in profit last year alone, are already too big, and they fail to provide care when we need it most.

While the new ban blocks Minnesota’s Department of Human Services from awarding contracts to for-profit HMOs and prevents these companies from offering new policies to state employees, HMOs run by UnitedHealth, Humana and Allina Health Aetna are still able to offer plans to groups and individuals, including through Medicare Advantage.

Minnesotans have an opportunity to lead the nation by telling for-profit insurers that their greed stops here. Our lives are at stake. That’s why we must prevent private insurers from taking a bigger bite of our health care, before it’s too late.

https://minnesotareformer.com…

Valley deserves and can afford ‘Medicare for All’

By George Bohmfalk, M.D.
Aspen (Colo.) Daily News, June 11, 2024

Editor:

Re: (“Grueter: Is valley health care on life support?” June 9, Aspen Daily News).

You can run but you can’t hide. Yes, health care in our beautiful Roaring Fork Valley is on life support, as it is across the entire country. People in all socioeconomic class levels are falling through the cracks by the millions every day, going without needed care and going bankrupt for care they can’t avoid.

Several well-intended local agencies like Valley Health Alliance, West Mountain Regional Health Alliance and Mountain Family Health Centers do their best to arrange care for folks, but to do anything really effective is going to require a national fix like “Medicare for All.” We can afford it; almost everyone will pay less than they do currently; care will still be delivered privately and all of us will have the peace of mind that our healthcare needs will be taken care of.

There’s not a single, valid reason not to have Medicare for All. We all deserve it. Demand it of all of your elected representatives.

https://www.aspendailynews.com…

A $600 Billion Swindle: Study Makes Case to ‘Abolish’ Medicare Advantage

"The time has come to declare MA a failed experiment," write the authors of a new paper.

By Jake Johnson
Common Dreams, June 10, 2024

A new academic analysis published Monday in JAMA Internal Medicine details the enormous sums that privatized Medicare Advantage plans have cost U.S. taxpayers in recent years and calls for the abolition of the program, which has been massively profitable for the insurance giants that dominate it.

Citing the nonpartisan Medicare Payment Advisory Commission, the paper notes that Medicare Advantage (MA) plans have overcharged the federal government to the tune of $612 billion since 2007—and $82 billion last year alone.

MA plans—now used by more than half of the eligible Medicare population—utilize a range of tactics to reap larger payments from the federal government, which provides insurers a lump sum for each Medicare Advantage patient. The size of the payment depends on the enrollee’s health, which MA plans are notorious for portraying as worse than it is in order to receive heftier government payments.

“Paradoxically, despite those overpayments, MA plans spend 9% less on medical services than [fee-for-service] Medicare spends for comparable enrollees,” reads the new study. “If MA plans pay for less care, where do the overpayments go? Some pay for supplementary benefits, although plans do not disclose how much they spend on them, and MA enrollees do not get significantly more dental care or incur lower out-of-pocket dental costs than those in FFS Medicare. Instead, overhead and profit eats up the lion’s share.”

The study’s authors estimate that MA plans’ overhead from 2007 to 2024 was $592 billion, which is “equivalent to 97% of taxpayers’ $612 billion overpayments to them during that period.”

Dr. Adam Gaffney, an assistant professor of medicine at Harvard Medical School and the lead author of the new study, said in a statement that “Medicare Advantage is a bad deal for taxpayers.”

“Money that could be used to eliminate all copayments or shore up Medicare’s Trust Fund is instead lining insurers’ pockets,” said Gaffney. “And the private insurers keep Medicare Advantage enrollees from getting needed care by erecting bureaucratic hurdles like prior authorizations and payment denials.”

Gaffney and study co-authors Drs. Stephanie Woolhandler and David Himmelstein—co-founders of Physicians for a National Health Program (PHNP)—argue based on their examination of Medicare Advantage’s decadeslong history that “the time has come to declare MA a failed experiment and abolish it.”

“Medicare Advantage plans have, in effect, stolen hundreds of billions from taxpayers,” says David Himmelstein, a lecturer at Harvard Medical School and a research associate at the consumer advocacy group Public Citizen. “And the private plans’ schemes also raise seniors’ Part B Medicare premiums. Even seniors who don’t choose to enroll in Medicare Advantage are subsidizing the private plans’ profits.”

The study’s authors observe that the elimination of Medicare Advantage would allow the federal government to use the roughly $88 billion in estimated MA overpayments for the coming year to instead “upgrade benefits for all Medicare beneficiaries.” Traditional Medicare typically does not cover dental, vision, or hearing services, which often leads people to choose MA plans.

“A smarter, thriftier way to expand benefits and lower out-of-pocket costs is possible for all Medicare beneficiaries, but first, we must eliminate MA and double down on traditional Medicare, covering all enrollees in an expanded and improved Medicare program,” the analysis concludes. “That would be a good deal for patients and taxpayers.”

Wendell Potter, a former insurance executive who has become a trenchant critic of Medicare Advantage, told Common Dreams that he agrees with the study’s authors that MA “should be eliminated.”

“Not only has it never saved taxpayers a dime since it was created during the George W. Bush administration, but it has cost us $592 billion over the last 17 years because of the high administrative costs inherent in the program and the way insurers have rigged the system to get paid excessively every year,” said Potter, president of the Center for Health and Democracy.

“The program is so entrenched, and the companies have so much political influence over Democrats as well as Republicans through campaign contributions and lobbying, that eliminating the program will be a heavy lift, at least in the near term,” Potter added. “That means that proposals to reform MA that address overpayments and abuses like prior authorization are essential and important for reform advocates to support.”

https://www.commondreams.org…

A $600 Billion Swindle: Study Makes Case to ‘Abolish’ Medicare Advantage

"The time has come to declare MA a failed experiment," write the authors of a new paper.

By Jake Johnson
Common Dreams, June 10, 2024

A new academic analysis published Monday in JAMA Internal Medicine details the enormous sums that privatized Medicare Advantage plans have cost U.S. taxpayers in recent years and calls for the abolition of the program, which has been massively profitable for the insurance giants that dominate it.

Citing the nonpartisan Medicare Payment Advisory Commission, the paper notes that Medicare Advantage (MA) plans have overcharged the federal government to the tune of $612 billion since 2007—and $82 billion last year alone.

MA plans—now used by more than half of the eligible Medicare population—utilize a range of tactics to reap larger payments from the federal government, which provides insurers a lump sum for each Medicare Advantage patient. The size of the payment depends on the enrollee’s health, which MA plans are notorious for portraying as worse than it is in order to receive heftier government payments.

“Paradoxically, despite those overpayments, MA plans spend 9% less on medical services than [fee-for-service] Medicare spends for comparable enrollees,” reads the new study. “If MA plans pay for less care, where do the overpayments go? Some pay for supplementary benefits, although plans do not disclose how much they spend on them, and MA enrollees do not get significantly more dental care or incur lower out-of-pocket dental costs than those in FFS Medicare. Instead, overhead and profit eats up the lion’s share.”

The study’s authors estimate that MA plans’ overhead from 2007 to 2024 was $592 billion, which is “equivalent to 97% of taxpayers’ $612 billion overpayments to them during that period.”

Dr. Adam Gaffney, an assistant professor of medicine at Harvard Medical School and the lead author of the new study, said in a statement that “Medicare Advantage is a bad deal for taxpayers.”

“Money that could be used to eliminate all copayments or shore up Medicare’s Trust Fund is instead lining insurers’ pockets,” said Gaffney. “And the private insurers keep Medicare Advantage enrollees from getting needed care by erecting bureaucratic hurdles like prior authorizations and payment denials.”

Gaffney and study co-authors Drs. Stephanie Woolhandler and David Himmelstein—co-founders of Physicians for a National Health Program (PHNP)—argue based on their examination of Medicare Advantage’s decadeslong history that “the time has come to declare MA a failed experiment and abolish it.”

“Medicare Advantage plans have, in effect, stolen hundreds of billions from taxpayers,” says David Himmelstein, a lecturer at Harvard Medical School and a research associate at the consumer advocacy group Public Citizen. “And the private plans’ schemes also raise seniors’ Part B Medicare premiums. Even seniors who don’t choose to enroll in Medicare Advantage are subsidizing the private plans’ profits.”

The study’s authors observe that the elimination of Medicare Advantage would allow the federal government to use the roughly $88 billion in estimated MA overpayments for the coming year to instead “upgrade benefits for all Medicare beneficiaries.” Traditional Medicare typically does not cover dental, vision, or hearing services, which often leads people to choose MA plans.

“A smarter, thriftier way to expand benefits and lower out-of-pocket costs is possible for all Medicare beneficiaries, but first, we must eliminate MA and double down on traditional Medicare, covering all enrollees in an expanded and improved Medicare program,” the analysis concludes. “That would be a good deal for patients and taxpayers.”

Wendell Potter, a former insurance executive who has become a trenchant critic of Medicare Advantage, told Common Dreams that he agrees with the study’s authors that MA “should be eliminated.”

“Not only has it never saved taxpayers a dime since it was created during the George W. Bush administration, but it has cost us $592 billion over the last 17 years because of the high administrative costs inherent in the program and the way insurers have rigged the system to get paid excessively every year,” said Potter, president of the Center for Health and Democracy.

“The program is so entrenched, and the companies have so much political influence over Democrats as well as Republicans through campaign contributions and lobbying, that eliminating the program will be a heavy lift, at least in the near term,” Potter added. “That means that proposals to reform MA that address overpayments and abuses like prior authorization are essential and important for reform advocates to support.”

https://commondreams.org…

The Many Disadvantages of Medicare Advantage

PNHP completed a far-reaching review of how Medicare Advantage disadvantages its enrollees, when it comes to financial burden, access to care, and clinical outcomes. The report and webinar are valuable resources.

Commentary:

By Ed Weisbart, M.D., PNHP National Board Secretary

Our health is just an innocent bystander in the wake of damage the corporate insurance industry is inflicting on Americans, and Medicare Advantage (MA) extends their greedy grasp to seniors and people with disabilities. As the new report, Taking Advantage, from Physicians for a National Health Program (PNHP) concludes, “MA represents the worst of private insurance coming to take over the best system of health care that America has to offer.” The findings were presented and discussed at a webinar on June 3.

This report reveals that the damages inflicted on us by MA are far worse and more pervasive than most had realized. Nearly twelve million people in MA are in networks that exclude more than 70% of the physicians in their county. More than seven million have such high out-of-pocket costs that they have no choice but to avoid medically necessary care. Prior Authorizations and other egregious HMO-style tools are rampant. Virtually none of these things happen in Traditional Medicare, and few people joining MA are aware that they are making this life-threatening gamble.

That’s right, it’s life-threatening. These MA programs are not just inconveniences or annoyances: they have been shown to kill us.

As an example, one of the dozens of studies cited in the PNHP report determined that people in MA are twice as likely to die after pancreatic cancer surgery than are people in Traditional Medicare.

Despite an overwhelming mountain of similar evidence, the insurance industry has the audacity to claim that they are the solution to America’s problem with inequities in healthcare. They justify this claim by the fact that people of color along with others with limited financial resources are more likely to sign up for MA than the rest of the country. But is that proof that they help, or is that not actually proof that MA is one of the drivers of health inequity?

Medicare itself is far from perfect; an unacceptably high 25% of white and 27% of Blacks in Traditional Medicare cite cost-related problems accessing care if they are in fair or poor health. The racial difference skyrockets in MA, where 35% of white Americans and 50% of Black Americans have this problem. MA is not a solution to inequities; it’s one of the drivers. People with more financial means reject the inferior insurance that is Medicare Dis-Advantage.

The PNHP report also cites studies demonstrating geographic disparities. 42% of physicians in metropolitan areas, and 65% of physicians in rural areas, are not in MA networks. Given the paucity of physicians in rural areas, this translates into prohibitively long commutes for a simple blood pressure visit. No one warns rural Americans of this when they opt into MA.

Insurance corporations have stopped hiding this from their shareholders. Tom Cowhey, chief financial officer of CVS, declared that that they are looking at pulling out of communities where they make less profits, cutting back on benefits like hearing and vision care, and maybe even more. As Cowhey put it, “the goal is margin over membership… Lose up to 10% of our Medicare members? That’s okay.”  CVS isn’t alone; Humana, Centene, and others are being just as honest about their indifference to the harms they cause in the name of their profiteering.

Compare CVS’ corporate mantra of “margin over membership” with a couple of the advocacy community’s flagship messages, “Patients Over Profits” and “Care Over Cost”. Our allies at People’s Action have a campaign centered on the mirror-image inverse of the insurance industry’s misguided philosophy and inescapable subordination to profits before people, regardless of the harm they cause.

The bottom line here, as spelled out in PNHP’s report and webinar, is that we are all being cheated by MA. Their industry was created with the promise that they could improve our health and lower costs by coordinating, informing, and managing care. Instead, the insurance industry has clearly learned that they make more profits by delaying, denying, and interrupting healthcare. They are not doing what they are paid (overpaid!) to do. It’s time we stopped them from taking advantage of us.

Despite the overwhelming evidence of harm, it would be a mistake to call for an isolated end to MA and add another disruption to healthcare for the millions of seniors and people with disabilities who are currently in MA. Many are there today because they are unable to purchase a Medicare supplemental policy and can’t dare risk the financial ruin of Traditional Medicare’s copays and deductibles. Many are in MA because of the promise of extra benefits (hearing, vision, dental, pharmacy, etc.) that go beyond what’s included in Traditional Medicare today, though we know few actually use those extra benefits and most find them to be grossly inadequate shadows of real benefits.

And, frankly, the data in PNHP’s report is national data about the industry as a whole, but there likely are some MA plans that are better than the patterns seen when data is averaged across the nation. Unfortunately, as pointed out in the webinar, there is virtually no public data for comparing those individual plans. To paraphrase Alex Lawson of Social Security Works, that’s like having the FAA tell us that one airline’s planes are frequently crashing, but not telling us which airline that is. Just let the free market sort it out.

We must continue to fight for improvements to Traditional Medicare, coordinated and synchronous with the elimination of MA subsidies, so that savings from MA can be used to help fund the improved benefits across all of Medicare.

Watch the webinar, and then take the actions suggested there. We win when we’re organized…

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.

Surgeon General Muddled Insights on Health Reform

A former Surgeon General, recently saddled with massive charges for an emergency visit, continues his interview, condemning medical debt and offering a facile dismissal of single payer.

Former U.S. Surgeon General: We’re Not Ready as a Nation for Single-Payer Healthcare; High Medical Debt ‘Obliterating Our Country’s Future’, MedPage Today, June 4-5, 2024, by Jeremy Faust

Question: People in the comments section of your article did say, “Well, wouldn’t Bernie Sanders’ approach be better? Wouldn’t single-payer be the way?” And I always answer this question by saying, “I don’t know. I know it works in other countries, but I’m not sure this country is set up for that.” What do you think about that?

Jerome Adams: “You also can’t go to a system where you’re giving universal access to healthcare and single-payer until you can agree upon what that actually means.

“A real example: you go to Canada or the U.K. right now, and you’ll have no shortage of people who will tell you that they’re waiting 6 to 8 months for their elective surgery [A]. In the United States, if you take someone who comes in to their doctor in pain or with a diagnosis and they get told that they’re going to have to wait 6 to 8 months for their elective surgery, they will lose their minds and they’ll be on the phone with their lawyer or their local news station right away.

“We have a different expectation for what universal access to healthcare and a single-payer system would look like here versus other countries. Until we’re ready to have a very mature and nuanced conversation about that and about the fact that we can do this, but if we do this it means that you’re not going to be able to get what you want when you want [B] just because that’s the cultural expectation here. I think there’s a lot of nuance here.

“So at the end of the day, to answer your question, I don’t think that we are quite ready as a nation to really go there even though it sounds good. But I also think that we don’t have to. Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country [C]. If you want more, you can buy it off of the market.

“I think there are hybrid systems that we can and should be thinking about that are predicated on giving people a baseline level of care, guaranteed, that do work and still allow a free market to exist.” …

Question: [T]alking about the high-deductible healthcare plans. I want to take the devil’s advocate [position] here and say, isn’t that the point of a high deductible?

Adams: … This is about the fact that 66% of bankruptcies in the United States are driven by medical debt. So regardless of whether you feel like it’s a person’s fault or not, we have a broader societal issue when … bankruptcies are being driven by this kind of debt [D]. That’s number one.

Number two, as I mentioned earlier about the Affordable Care Act [ACA], we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans [E]. It’s not that they made a choice, it’s that that was the only option that they were given, or the plans are priced such that that’s the only one where I can afford the premium to go on. So it’s not like people out there are making the choice that they want this high-deductible health plan, they’re being pushed in that direction.

The final point I’d make about the high-deductible health plan … the whole premise of the high-deductible health plan was also to include HSAs, where you contribute to these HSAs on a monthly basis so you’ve got something in the kitty in case you have an emergency. … But also we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HSA [F].

So you have a system set up that’s dysfunctional because people aren’t educated and they aren’t contributing to it. Even when they do everything right — like I do, I max out my HSA — you still could get hit with a bill in January [G] as opposed to December. Mayo Clinic, in this instance, isn’t waiting until December to get their money. They want their money now. and so I’ve got to come up with it now.

… Nobody thinks that they’re going to need emergency medical care! Heck, I didn’t think that I was going to pass out at a medical meeting after a hike. …

No one’s talking about this on the campaign trail. [H] You don’t hear Biden or Trump talking about this on the campaign trail. You don’t hear people running for Congress talking about this on the campaign trail, but it is 66% of bankruptcies. It’s literally just obliterating our country’s future in terms of putting people in medical debt. …

Again, I raised this because I want people to really understand that this is hitting all of us and it is not sustainable.

[W]e highlight the need for increased transparency and pricing. [I] … we also need to look at state policies to help people avoid surprise medical bills, not just for out of network, but again, from January surprises and all sorts of different ways that people run into surprise medical bills. …

We need collaboration between providers, insurers, and healthcare systems, to really figure out how we unstick this broken system.

Then, we need to improve high-deductible health plans. I think that it’s still workable, [J] but my situation showed that high-deductible health plans are actually setting a lot of people up for medical bankruptcies and the burden of medical debt.

[ HJM comments keyed to bracketed letters ]

Comment:

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

Dr. Adams engages in policy analysis by anecdote. This is hazardous; omitting relevant evidence leads to faulty conclusions. He thus dismisses single payer in cavalier fashion. Below is a point-by-point critique (with, I should note, quite a few points of agreement):

[A] “They’re waiting 6 to 8 months for elective surgery” in Canada and the UK. These numbers aren’t relevant to US single payer. For starters, the UK NHS is under assault by the Tories. More generally, the OECD record for elective surgery wait times is quite good, with medians of 4-7 weeks in the best-performing countries … and we’d be starting with higher spending and more surgeons than any of them. Of course, elective surgery isn’t urgent, by definition. On other measures of access, such as for primary care, the US lags far behind other OECD nations.

[B] “If we do [single payer] it means you’re not going to get what you want just because that’s the cultural expectation here.” Hmm. Is the US cultural expectation to skip or delay care for financial reasons? To experience 2-3 years’ lower lifespan? Today, while the best-insured may get the medical care they want right away, most have to wait or can’t get it at all.

[C] “Switzerland, for instance, has a system where they provide access to a certain level of care for everyone in the country.” That “certain level of care” is standard and comprehensive. Only 8.5% of spending is voluntary health insurance.

[D] “66% of bankruptcies in the United States are driven by medical debt.” Got that right!

[E] “about the Affordable Care Act, we’re now in a place where almost 60% of people with employer-provided health insurance — the ‘good insurance’ — are forced onto high-deductible health plans.” Yup – forced into high deductibles. Not a choice.

[F] “we know that many people, particularly from marginalized communities like Black and Brown individuals and individuals from under-resourced communities, often are uneducated about their HSA or don’t contribute to their HAS.” Right – likely can’t afford to contribute. HSAs are regressive, benefiting the healthy and wealthy. They worsen inequality.

[G] “you still could get hit with a bill in January.” Right again … several thousand dollars within the deductible, all at once, with no financial reserves.

[H] “No one’s talking about this (medical debt & bankruptcies) on the campaign trail.” True. Biden mentions lower prescription drug costs for seniors, which help a bit. Trump discusses ending the ACA. Some progressive Congressional candidates discuss single payer.

[I] “we also need to look at state policies to help people avoid surprise medical bills.” We’ve tried that, and federal policies too. It doesn’t work – too complex and gameable, and even if it did succeed it would leave unresolved 25 other major problems with our fragmented insurance.

[J] “we need to improve high-deductible health plans. I think that it’s still workable.” Not really. The problem with high deductibles is that they leave individuals & families financially vulnerable. Other wealthy nations don’t use high deductibles. With good reason – they impair access to care, impoverish people, punish the poor, and don’t control health care costs

Come on, Dr. Adams – endorse a real solution, one proven in dozens of other countries. It’s nice to hear from a former Surgeon General on problems with our insurance. How wonderful would it be for him to endorse the effective and enduring policy solution – single payer.

https://healthjusticemonitor.org…

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