PNHP

Latest Corporate Intermediary Scam, For Out-of-Network Charges

Latest Corporate Intermediary Scam, For Out-of-Network Charges

Here’s the latest corporate innovation to extract resources from health care, by creating yet another inefficient but highly profitable intermediary. This time it’s for out-of-network charges. Who pays more? Patients.

Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill, The New York Times, April 7, 2024, by Chris Hammy

MultiPlan is a little-known data analytics firm that works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.

Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.

But when when employees see a provider outside the network, many insurance companies consult with MultiPlan, which typically recommends that the employers pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a saving for the employer. But, the Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, according to testimony by two of its executives. Last year alone, MultiPlan told investors it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

The little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay. In addition, providers have seen their pay slashed, and employers have been hit with high fees. In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient.

After MultiPlan’s founder sold it to private equity investors in 2006, the company pursued a more aggressive approach. It embraced pricing tools that used algorithms to recommend lower payments, and no longer protected patients from having to pay the difference.

Once insurers were no longer obligated to use the nonprofit database, FAIR Health, they began looking for ways to combat billing and other charges they considered egregious. Insurers contended that overbilling would skew payments too high. Cigna: “We need someone external to Cigna to develop acceptable rates.” UnitedHealthcare emphasized companies still using FAIR Health, “understand they don’t want to be on that program anymore.”

UnitedHealthcare had a big incentive to encourage this change. When it processed claims from employer plans using FAIR Health, the insurer collected no additional fee. But when it used MultiPlan, it typically charged employers 30 to 35 percent of the difference between the billed amount and the portion paid.

MultiPlan, too, charged a percentage of the savings, meaning it could make more by recommending lower payments. (FAIR Health charged a flat fee.)

While UnitedHealthcare was MultiPlan’s largest customer, Cigna and Aetna also embraced its tools and fee model. Other insurers that work with MultiPlan include Kaiser Permanente, Humana and some Blue Cross Blue Shield plans. Employers with self-funded plans administered by insurers include large companies like Coca-Cola and AstraZeneca and smaller organizations like school districts and union locals.

Comment:

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

Theoretically, health insurance should allow us to equitably pool our funds in order to make health care both accessible and affordable for everyone participating. We have had a goal to expand that to include everyone. However, we have relied heavily on the private insurance industry which has engaged in business activities designed to increase profits for its shareholders and compensation for its executives. These activities have impaired access and resulted in an increase in medical debt for those for whom the system should be designed: the patients.

Not only are the insurers placing financial pressures on the physicians, hospitals, nursing homes and the many other providers of health care services, but they have also been attempting to further increase their incomes through increases in insurance premiums, deductibles, copayments, excessive prior authorization requirements, narrow provider networks, and limitations in coverage. Frequently these are applied in a manner that denies patients needed care, care that they can usually obtain if they are enrolled in a government program such as Medicare, Medicaid, VA Health if their particular program has not been overly privatized.

So what is the insurance industry offering us now? An example in the article: The physician provides medical services and bills $1000 for them. The self-insured employer pays the fee determined by MultiPlan which is only $200 of the $1000. The amount “saved” for the employer is $800 of which MultiPlan receives 7% or $56 and the insurer receives 35% or $280. A $800 balance remains which “the patient is potentially on the hook for.” Whether the patient or the physician is out the remaining $800 of the medical bill, clearly the insurers are no longer fulfilling what we consider the traditional function of insurers, yet they are leaching much of our health care dollars for worthless functions.

This is yet another intermediary strategy to extract profits. This time it focuses on out-of-network charges (those unregulated by the “No Surprises” Act). The “business model” is to add complexity via inserting extra corporate actors in a previously simpler arrangement. Just like Pharmacy Benefit Managers insert themselves between drug companies and pharmacies. They promise savings, but actually increase costs. This removes resources that should be spent on health care, and redirects them to shareholders of for-profit entities. Patients pick up the slack.

We’ve long said that it is time to get rid of the private insurers and their add-on leaches, and this development seems to make it even more of an imperative. It is high time to improve Medicare and to expand it to cover everyone as a single payer system that is equitably funded through progressive taxes.

Of the multitude of New York Times reader comments for this article the most popular was by a Canadian physician commenting on their single payer system who wrote,” The US needs to get their act together.

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.

Do No Harm

Exploring Chicago’s rich history of physician activism

By Judith Weinstein
Chicago Health, April 8, 2024

The day that physician residents and fellows at Northwestern Medicine voted 794 to 148 to unionize, some shared their joy on social media.

“So proud of the community of residents and fellows who made this happen. Unions increase workers’ democratic voice; raise wages and build wealth; and improve conditions for all workers. WE DID IT,” wrote third-year resident Hebron Kelecha, MD, on X (formerly Twitter).

Northwestern Medicine’s physicians-in-training aren’t Illinois’ first group to unionize (800 residents at University of Illinois Chicago unionized in 2011), but Northwestern’s group is the largest in the Midwest, with almost 1,300 doctors.

While the idea of physicians unionizing is relatively new, activism among physicians isn’t. Physicians regularly advocate for their patients. Many operate under the Hippocratic concept of, “First, do no harm.” 

But what if the harm is coming from beyond anything the physician and patient can control, such as from the environment, structural racism, insurance companies’ denial of care, or lack of access to healthy food?

The antibiotic prescribed for a single mother’s urinary tract infection, for example, may be less important to her than finding a job that pays a living wage, securing childcare for her two children, and moving to a safer neighborhood. The hernia repair operation that a laid-off factory worker needs may be less important to him than his lack of health insurance, his need to acquire skills in order to find a new job, and his concern about making rent payments while unemployed.

That’s when a physician might switch from advocacy — working on behalf of an individual patient — to activism, which involves pushing for social and political changes that impact entire communities. Still, if physicians take an oath to do no harm, is fighting the systems that harm their patients considered activism? Or are they simply doing their job?

Twenty years ago, an issue of the American Medical Association’s Journal of Ethics focused on physician activism. In his opening letter, Editor Jeffrey Kullgren wrote, “If we are truly dedicated to improving the lives and well-being of our patients, and if we honestly care enough about the vulnerable persons that have trusted us to care for them, we have an obligation not only to provide health care of the highest quality, but also in some way, shape, or form to be active in public policy changes needed to better their lives.”

Former U.S. Surgeon General Antonia C. Novello, MD, DrPH, embodies that concept. “I loved the practice of medicine, where the focus is on individual patients, but early in my career I realized that my strongest interest is in improving the health of large population groups,” Novello said in an interview in the same Journal of Ethics issue. “I wanted to be able to do something about the major health issues facing people in this country, such as the need to increase access to healthcare for the uninsured, the need to ensure that the healthcare in this country is high-quality care, and the need to improve the health status of Americans through greater emphasis on prevention and healthy lifestyles.”

To address the issues, Novello went from the medical clinic to the political arena. Yet, for many physicians, activism — especially in the wake of Covid-19 — increasingly happens in the clinic and on the streets.

The legacy of Quentin D. Young, MD

Chicago is an epicenter of corporate and political power. It’s a city of health insurance and pharmaceutical companies, and the headquarters for many medical associations, including the American Medical Association. One of the country’s largest safety-net hospitals also calls Chicago home. John H. Stroger, Jr. Hospital (formerly known as Cook County Hospital or more commonly “County”) has attracted and shaped many physician activists, including the legendary Quentin D. Young, MD.

Young was born in 1923 on Chicago’s South Side, the son of immigrants from Eastern Europe. He attributed his activism to an early awakening to injustices far and near, including the impacts of segregation on Black people’s health. In 1981, he co-founded the Health and Medicine Policy Research Group (HMPRG) — an organization that would “uncover and challenge health inequities in Illinois.” The choice to list health before medicine in the name was deliberate.

Young believed fervently in healthcare for all — “Everyone in, nobody out!” was his mantra — achievable only through a universal-financing mechanism. Countries typically achieve universal health coverage through single-payer financing. Medicare, for example, is a form of single-payer healthcare; however, it’s not universal health coverage because not all U.S. citizens qualify for Medicare — only those age 65 and over.

The United States is the only high-income country in the world without universal health coverage. While most Americans agree that healthcare is a basic human right, how to finance such care, especially via the government, is as divisive a topic as abortion or politics. 

“For Quentin, it was a moral argument,” says Margie Schaps, HMPRG’s executive director since 1993. “He wasn’t a believer in incrementalism. If you want transformative change, small steps will not get you there. And Quentin wanted transformative change.”

The revolution did not happen in Young’s lifetime, but other generations of physicians influenced by his moral argument picked up the mantle. 

A direct descendant in the physician activist family is David Ansell, MD.  

Today’s physician activist leadership

To talk with Ansell is to receive a crash course in the social determinants of health and the industrial healthcare complex. He’s currently senior vice president for Community Health Equity at Rush University Medical Center and associate provost for Community Affairs.

Ansell went to medical school in upstate New York to “do good for people.” But when handed a stethoscope branded by Eli Lilly, he thought about leaving for forestry school. 

Unfortunately for the trees, Ansell stayed the course and upon graduation headed to Chicago with one intention: to train under Young, then-chair of medicine at Cook County Hospital.

“I came to Chicago because I was an activist, and I learned how better to be an activist,” Ansell says. 

Ansell’s 2011 book, County: Life, Death and Politics at Chicago’s Public Hospital, includes an introduction from Young and chronicles the history of Cook County and his years there.

Activism is part of the social medicine skills that Ansell and co-author Kristen Pallok, MD, describe as key in the 2022 AMA Journal of Ethics article “Should Clinicians Be Activists?” The article also explores reasons physicians may shy away from activism.

Some physicians may consider themselves apolitical, or they view any treatment as better than no treatment. Others might disagree that healthcare is a human right, or fear for their employment. And some physicians don’t think they have the time or expertise for health activism.

Ansell has never been one of those physicians. Rush University leadership tapped him after he’d spent 30 years working at Chicago’s safety net hospitals (more than half at County, the rest at Mount Sinai Hospital) to serve as its inaugural chief medical officer.

I thought, what the heck? It’s across the street,” Ansell recalls. 

The view from Rush changed his perspective entirely. 

“I understood for the first time how structural racism in health inequities were built into one street,” Ansell says. “There were two worlds, all tied to a capitalist system where White people have better insurance, and Black and Brown people are at the bottom.” 

He saw the contrast between those worlds most starkly in organ transplant patients. “In my 30 years at [Cook] County and Sinai, none of my patients ever got a life-saving organ transplant. But the organs transplanted into White patients all came from Black and Brown bodies.” 

Achieving equity

While demonstrating via sit-ins and marches can be an effective form of activism, using research to take on a system and force it to change is especially powerful. Under Ansell’s direction, Rush became one of the first hospitals in the country to establish health equity as a system strategy and measurable organizational priority.

Ansell believes that an increasing number of medical students come to Rush because of this strategy. The health equity and social justice leadership course is often oversubscribed, but medical students train across all curricula in anti-racism and health equity. 

And for Ansell, universal healthcare offers a direct path to more equitable healthcare. 

“The nature of our health system perpetuates this inequity that puts Black and Brown people at the bottom of the pile; it’s a caste system. Single-payer, or something like it, where everyone gets the same card at birth, will improve outcomes for the population,” he says, adding, “But that’s not enough.”

Physicians for a National Health Program (PNHP) advocates for universal, comprehensive single-payer national health insurance, joining with other organizations to fight racism and advance social justice. Founded in 1987 in Cambridge, Massachusetts, by Steffie Woolhandler, MD, and David Himmelstein, MD, the program moved its headquarters to Chicago in 1991. The city’s strong activist cohort that included physicians Young, Gordy Schiff, MD, and Claudia Fegan, MD, made the new home appealing.

Susan Rogers, MD, the immediate-past-president of PNHP, spent most of her clinical career as an internist at Stroger Hospital. She currently serves on the faculty of Rush University and its medical school admissions committee.

Rogers grew up in Hyde Park “which was so totally integrated, I never knew there were all-White or all-Black neighborhoods,” she says. 

In 7th grade, her mother took her and her two siblings to march with Martin Luther King, Jr., to protest school segregation. “It was then I realized how awful things were. My mother was pushing this, so I thought, this must be important.” At the brand-new Kenwood High School, as the Vietnam War was escalating, “that’s when I had a sense of using my voice to protest for change.”

As a Black student at the small western college that Rogers first attended, she “wasn’t exactly welcomed,” so she returned to Chicago to study biology at Roosevelt University. Unsure of whether she wanted to be a teacher, nurse, or doctor, she went on to graduate from medical school at the University of Illinois. 

Rogers loved being an attending at Stroger Hospital. “I went to County to take care of Black people. That is part of my activism.”

Educating doctors in activism

Now, Rogers and the Rush admissions committee look for a wide array of applicants. Some of them have volunteered locally or globally, and many are attracted to Rush because of its affiliation with Stroger Hospital. 

That said, Rogers notes the lack of Black physicians in the U.S., which correlates with the demographics of medical school applicants. Per Rogers, most applicants come from families with incomes in the top 20%, and many are children of physicians. 

Rogers attributes much of the inequality in health outcomes to income inequality and to institutionalized racism. 

“Because this country is so segregated, people don’t grow up really knowing people who did not grow up like them,” she says.

Philip Verhoef, MD, PhD, succeeded Rogers as PNHP’s president. His activism began during his training as a pediatrics resident at the University of California-Los Angeles, where he became involved with Doctors for America, a nonprofit dedicated to improving healthcare access.

Verhoef moved to Chicago to get additional training in critical care at the University of Chicago Medicine. “That is really when I became activated in the single-payer movement. PNHP was based in Chicago, and there were a lot of activists,” he says.

Now, though, Verhoef says he understands why younger physicians might avoid activism. Sometimes saddled with hundreds of thousands of dollars of debt, just starting their practices or families, they have neither time nor energy for activism. That lack of resources also applies to physicians on the front lines of inequity in emergency rooms, trauma centers, and safety-net hospitals.

While an event sparks some physicians into activism — such as the Flint, Michigan water crisis, exposed by a pediatrician — Verhoef sees himself as an educator for activists, through his role with PNHP. “Students don’t know the system they’re getting into.”

Like Ansell, Verhoef says that activism requires a certain skill set. “Let’s teach [doctors] how to be an activist, not just an advocate, because it’s part of your professional identity. 

We are at the top of the food chain, and people listen to us.” 

The medical residents and fellows at Northwestern University’s Feinberg School of Medicine experienced just how powerful their voices can be when they secured unionization. 

Verhoef says he sees clear benefits in their action. “We built many of our hospitals to function on the backs of resident labor, ripe for exploitation. Why do we work as much as we do and have no say in this process?”

Yet, he says, there’s more work ahead. “We need to start using our voices to get the healthcare we want and deserve in this country. That is our moral obligation as healthcare professionals.”

More physicians than ever, it seems, are doing exactly that.

https://chicagohealthonline.com…

May Day 2028 National Strike: Focus on Medicare for All

Prominent labor leader Shawn Fain has proposed a national strike of unionized workers four years from now, to highlight and advance the needs of workers and their families. This riveting vision will be super-charged with a focus on unified public funding of health care.

The UAW’S 2028 National Strike Should Center Medicare for All, JACOBIN, March 31, 2024, by Jonathan Michels & Will Cox

United Auto Workers president Shawn Fain has called on unions to come together for a national strike on International Workers Day, May 1, 2028. This is a radical idea – and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

Shawn Fain’s call to utilize labor power – four hundred thousand working members and six hundred thousand retirees make up the UAW alone – for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers – union and nonunion alike – willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028.

Fain frames workers as warriors locked in a struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

Of all the social reforms before the American public today, single payer is not only the most popular – a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care – it also has the potential to be the most transformative.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. It is the process of organizing and building solidarity that is much more important than the turn out for a single event, march, or rally.

In order to win public goods, the union movement will have to become a mass movement.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests – and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector – from the factory worker to the academic, from physicians to food service workers.

You need a broad social coalition and labor needs to be out front.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Comment:

By Don McCanne, M.D.

How long have we been doing this? (a long time)

How close are we to our goal? (not very close at all)

Do we anticipate a legislative solution? (not soon, but we should forge ahead anyway)

Do people want something done with our health care system?

There does seem to be wide agreement that our system is not working as it should be. Medical debt is a major problem faced not only by the uninsured but also by the insured who have difficulty paying premiums, deductibles, copayments, and disallowed charges. People frequently find that they cannot afford the care or medications they need.

People do not oppose government participation in health care since many enroll in Medicare, Medicaid, VA health, and other government programs as appropriate. Polls indicate support for publicly funded programs. Politicians promote government programs. Biden is supporting the ACA plans, and Trump is supporting government plans “better than Obamacare” though he hasn’t stated what that would be.

The point is that when the public realizes that we can have a plan that will ensure access to health care for everyone while keeping it affordable for everyone, eradicating the problem of medical debt, maybe it is time for mass public action. The JACOBIN article suggests a date of May 1, 2028 (and it is well worth reading the fairly long article in its entirety), but actually the organizing can begin right now.

Yes, there is a political divide in our nation. But the divide here is not so much left and right as it is all of us workers on all levels and the billionaires. We want health care for all the people, and, yes, we’ll include the billionaires.

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.

MAGA Mike Johnson Explores Medicare for All

GOP Representative Mike Johnson, aiming to gain Dem support for his threatened position as Speaker, told a reporter he is willing to consider Medicare for All. He said that universal public insurance works well in countries with robust market economies and even conservative governments.

Embattled House Speaker Reaches Across Aisle to Dems on Health Reform, USA Wire Service, April 1, 2024, by Bir Nisan

Mike Johnson (R, LA), Speaker of the US House of Representatives, is struggling with a razor thin GOP majority and a looming vote on his leadership position due to a petition from Marjorie Tayler Greene (R, CO). He is contemplating desperate measures to garner support.

In an interview, Mr. Johnson offered a surprising reply to the question, “Are you seeking Democratic votes for your Speaker position?”

“Public perceptions of my absolute partisanship are mistaken. Of course, I vigorously advance Republican values and policies. However, when opportunities arise, I’m open to building alliances across the aisle.

“Here’s one example. My staff recently reviewed international experience with health insurance. They found that having public agencies pay for all medical care works very well in numerous nations. It saves money and is popular. All of these countries have thriving free market economic systems, and many have conservative governments.”

Rep. Pramila Jayapal (D, WA), lead sponsor for H.R. 3421, the Medicare for All Act (113 co-sponsors), expressed enthusiasm for the Speaker’s sentiment. “I’m surprised, given his past positions on health reform, not to mention on many other priority progressive issues. But if the Speaker has seen the light on this issue, we’re more than willing to work together.”

Other GOP lawmakers declined comment.

Johnson added, “As a very religious person, I believe health care is a moral imperative. They say only Nixon could undertake rapprochement with China. Well, maybe only Mike Johnson can join a cross-party coalition for Medicare for All in the US.”

Comment:

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

Amidst the most severe and vitriolic political divisions in memory, and a historically intense presidential election campaign, this report is eye-catching, even shocking.

Could it be that the Speaker, to this point a stalwart opponent of Democratic (let alone progressive) legislation, is offering an olive branch on comprehensive insurance reform? Has his staff done their homework and convinced him of what we in the single payer movement have been saying for years? That is, that single payer allows us to achieve the moral goal of universal access to health insurance, within the context of (and strengthening) a robust market economy?

It feels like a dream.

Well, yes, it is a dream. An April Fool’s fantasy.

Sorry my friends. Maybe someday this story, or one like it, will come true.

Meantime, let’s focus on strengthening the role of Democrats, and progressives in particular, in Washington DC and across the nation. And continue our quest for generous, efficient, people-oriented health insurance – single payer.

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.

The UAW’s 2028 National Strike Should Center Medicare for All

United Auto Workers president Shawn Fain has called on unions to come together for a national strike in 2028. This is a radical idea — and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

By Jonathan Michels and Will Cox
Jacobin, March 31, 2024

Fresh off their historic labor victory against the country’s Big Three automakers, the United Auto Workers (UAW) are laying the groundwork for workers across multiple sectors to join them in a general strike on International Workers Day, May 1, 2028.

UAW president Shawn Fain’s call to utilize labor power — four hundred thousand working members and six hundred thousand retirees make up the UAW alone — for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers — union and nonunion alike — willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A New Opening for Militancy

Roderick Jaynes hurriedly inspects his welding work as another massive slab of steel shuttles toward him on the production line. Jaynes grips the welding gun to secure pieces of galvanized metal underneath the slab.

A shower of welding sparks lights up around the autoworker, only to dissipate against his heavy leather jacket. Jaynes sucks in a mouthful of purified air circulating inside his helmet, which prevents him from breathing in toxic weld smoke.

The voltage on the welding guns is turned up high so that they burn hot and fast, allowing him to keep pace with the quick tempo of the production line. The goal is to do the job right but also quickly, so you don’t cause the rest of your team to fall behind.

The kind of solidarity displayed on the assembly line must be replicated at the bargaining table as UAW workers at Daimler Truck North America (DTNA) gear up for a contract battle, which includes the possibility of a strike. With a looming contract expiration on April 26, contentious negotiations are already underway, pitting Daimler Truck against seven thousand plant workers throughout Georgia, North Carolina, and Tennessee. On March 8, 96 percent of UAW workers across DTNA voted to give their leadership the ability to call a strike when the contract expires, if necessary.

Daimler Truck posted record-high revenues of $60.3 billion in 2023, an increase of 10 percent compared to the previous year. UAW members who work at DTNA, meanwhile, say they are beaten down by stagnant wages, increased cost-of-living expenses, and a demoralizing work environment.

The focus of the UAW leadership on eliminating tiered contracts, organizing nonunion auto plants, and inciting workers to understand that the union’s struggle is part of a larger class struggle would have been unthinkable several years ago, when the union was mired by corruption at the highest levels. Fain’s class-war rhetoric evokes the radical strains of the UAW that animated the labor upsurge of the 1930s and 1940s. Even if this revived militancy is not uniform across all of the union’s locals, the sharp turn has ignited energy among many rank-and-file members like Jaynes, a UAW member and production worker at a DTNA plant in North Carolina.

Jaynes hopes union negotiators will align their contract to enable them to participate in the unified May Day contract expiration in 2028 outlined by Fain. Calling for a strike is not to be taken lightly. Strikes are won when they have overwhelming support from the workers who have the most at stake. The ability to move hugely profitable products — in this case, cars, trucks, and buses — along with the power to stop production and shut down assembly and parts plants, into which corporations like Daimler Truck invest massive amounts of money, puts autoworkers in a unique position to make demands from capital.

“Workers in heavy industry have tremendous power to twist capitalists’ arms,” Jaynes told Jacobin.

“Auto, steel, rubber, aerospace, military defense production, oil have always played a really key role in the labor movement, and that remains true today, despite changes in the global economy,” he said. “I think that that was really hammered home for a lot of people after the [2023] UAW strike, when people said, ‘Holy shit, autoworkers really have power!’”

From Rights on Paper to Rights in Action

Most of the credit for turning the union around has been heaped upon Fain, but his ascent to the UAW presidency represented a decisive victory for rank-and-file members who have been fighting for years for a more democratic, more militant approach within the union. In the wake of a protracted federal corruption probe that sent two UAW presidents to jail, UAW members voted in 2021 by an overwhelming margin to adopt a “one member, one vote” method for selecting their leadership — a development that paved the way for the election of a new reform leadership, headed by Fain, in late 2022 and early 2023.

These victories were made possible, in part, by the efforts of a newly formed reform caucus within the union, Unite All Workers for Democracy (UAWD). One problematic aspect of this process, it’s worth adding, is that it involved the direct involvement of the state into the affairs of the UAW; it was a federal consent decree stemming from the government’s probe into corruption within the union that led to the referendum vote for “one member, one vote.”

The shakeup in the UAW set the stage for the UAW’s militant “stand-up” strike in 2023 against the Big Three (Ford, General Motors, and Stellantis) and fueled the union’s subsequent campaign to organize autoworkers at nonunion workplaces. That effort is already paying off. The UAW recently announced that ten thousand autoworkers signed union cards at thirteen worksites, including a majority of workers at two plants in the heart of the anti-union South.

The stand-up strike showed that labor still has the power to force concessions from management. More importantly, the labor campaign provided an example of a rank-and-file movement that can link its struggle to the larger political economy.

“This new union leadership has created a new opening to building a labor movement that is more militant but also, taking that a step further, that can bring up political demands,” Jaynes said. “The significance of Fain’s call to align contracts is that they are thinking along these lines.”

There is a lot at stake for workers on the line in an actual strike. Strike threats that arise from within the labor movement are often made to achieve strategic goals. For example, Sara Nelson, international president of the Association of Flight Attendants–CWA, called for workers to discuss the possibility of a general strike to end the government shutdown in 2019.

Outside the labor movement, there are periodically well-meaning calls for a general strike. However, as Joe Burns points out, the recent “dizzying number” of calls for a general strike mostly emanate from social media and are primarily issued by activists disconnected from unions and workers.

But Fain and the UAW, riding a wave of goodwill from the 2023 strike, appear poised to revive a fighting spirit among workers not seen since its early days as a militant union. Just a little over a year after the UAW’s founding, autoworkers in Flint, Michigan, staged a sit-down strike in late 1936 and early 1937. Known as the “strike heard ‘round the world,” the action grew the UAW membership rolls from 88,000 members to 400,000 within a year and helped transform labor in America into a fighting force capable of bringing capital to its knees.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028. Although this type of solidarity among unions is a tall order, “there is an actual game plan laid out that could lead to a general strike on May 1, 2028,” said Barry Eidlin, an associate professor of sociology at McGill University in Montreal.

“That is far different from the usual just sort of posting up on some telephone poles and . . . issuing some call on Twitter for a general strike and expecting people to do that,” Eidlin said.

In numerous speeches, Fain frames workers as warriors locked in struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

“We have the right to strike,” Fain told UAW delegates in 2023. “We have the right to arbitration, to collective bargaining. But we have not yet won the rights that will fundamentally change this union and change this country.”

“We’ve not yet won racial and economic justice in the workplace for all of our members,” he said. “We’ve not yet won retirement security and health care and pensions for all.”

Labor movements coalesce around common interests. Likewise, public goods like Medicare for All are capable of uniting the public across the political spectrum. Of all the social reforms before the American public today, single payer is not only the most popular — a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care — it also has the potential to be the most transformative.

Authors Beatrice Adler-Bolton and Artie Vierkant point out that health is one of the pillars underlying the entire structure of our political economy, and yet there is a contradictory relationship between health and labor under capitalism. “Capitalism has defined ‘health’ itself as a capacity to submit oneself to labor,” note Adler-Bolton and Vierkant in their book Health Communism.

To directly confront the health economy is to take on capitalism itself. On the one hand, a national health program is merely a needed social reform that is commonplace in other wealthy countries. On the other hand, conservative forces in the United States correctly understand single payer’s revolutionary potential, as evidenced by their decades-long opposition against its passage.

Fain is already connecting autoworkers to the larger class struggle, because he understands the accumulation of wealth in our economy rests on the shoulders of American labor.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

The UAW’s clarion call for class struggle should resonate with single-payer supporters, who face tremendous opposition from entrenched, well-financed private interests that stand in the way of transformational change. Instead of the Big Three automakers, the single-payer movement must slay the hydra of American capital, including private health insurers, Big Pharma, hospitals, private equity firms, and interest groups such as the American Medical Association.

Even if a general strike fails to materialize in 2028, connecting the autoworkers’ struggle to broader social movements is a roadmap for the single-payer movement if it wants to build the kind of power that can help it win. All of the traditional avenues — relying on electoral politics, reasoning with the boss, lobbying legislators — have proven to be dead ends because they fail to confront the imbalance of power head on.

Medicare for All Is Freedom

Backaches. Knee pain. Burnt flesh from hot metal slag. UAW workers know all too well that assembly work is dangerous and wreaks havoc on the body.

“It’s part of the nature of the work of being an industrial worker,” Jaynes offered. “If you’re not looking out for yourself, if you’re not wearing the proper PPE [personal protective equipment], knee pads, you’re gonna fuck up your body.”

Jaynes regularly engages in physical conditioning at home to avoid greater injury on the job. Nevertheless, he shrugged off the idea that risk to life and limb was out of the ordinary.

“There’s an understanding that we deserve to be fairly compensated for that work and for the hazards to our health,” he said, “and conditions need to be improved where they can be improved, and yeah, we need good health care.”

Few issues have as much potential as health care to unite the American working class in a common struggle. The reason public goods appeal to working people is that they are based around meeting human needs and not profits. Medicare for All, for instance, would guarantee workers health care no matter what happens to their jobs.

Health care costs are a drain on workers’ take-home pay, even for those fortunate enough to have employer-provided insurance. In 2023, workers paid an average premium of $8,435 for individual coverage through their employer and a whopping $23,968 just to cover their family, according to a survey conducted by the Kaiser Family Foundation. While workers’ wages fail to keep up with inflation, health care corporations continue to rake in billions.

Nonunionized workers are particularly vulnerable to layoffs and poor working conditions, but health care is precarious even among organized workers. When your health care depends on your job, your employer literally has the coercive power of life and death. Apart from a paycheck, the tie that binds most workers to their jobs today is their health benefits.

Medicare for All would cut the cord.

Under a single-payer system, health care would be free at the point of service. Premiums, deductibles, and copayments would be eliminated. Everyone would have the same health coverage, including the foreman, the CEO, the person working next to them on the assembly line, and even their recently retired coworker.

With health care no longer tied to employment, workers would be emboldened to leave their jobs or stay and agitate for a union. Self-employed workers such as writers and artists could focus on their craft and less on scraping together part-time gigs to pay for their medical bills.

In Canada and other Western countries with universal health programs, the public is at least protected from the threat of losing their medical benefits. For Canadian workers, single payer is like the ultimate strike fund.

“The basics are all covered in terms of hospital care, physician care, specialty care, all that stuff is covered,” said Eidlin, who is based in Canada. “So for [Canadian] unions, that stuff is not stuff that they have to bargain about at the negotiating table. They can bargain for other things.”

With health care off the table under a single-payer system, unions are free to devote more energy to bargaining for things like increased staffing, worker safety, and better wages.

Not so in the United States, where our dysfunctional, multitiered health system requires unions to commit resources toward maintaining hard-won private welfare states through the provision of basic health benefits for their members.

Consequently, health and safety have been catalysts for the overwhelming majority of American labor struggles. Among the many issues that touched off the Flint sit-down strike of 1936–37 was the horrific wave of autoworker deaths from heat exposure just months earlier. This concern for health and safety was reiterated following the strike at the first national convention of the Congress of Industrial Organizations (CIO) in 1938, when UAW president Walter Reuther, along with other leaders in the CIO, called for a national health insurance program.

We can look to the West Virginia teachers’ strike over health insurance or the widespread labor uprisings fueled by the COVID-19 pandemic as recent examples. Even large unions like the UAW, Teamsters, and the United Mine Workers of America have historically been forced to include private health plans as just another bargaining chip in lieu of competing demands, including national health insurance.

When employees depend on the employer to absorb the cost of medical care, they are playing a rigged game.

History shows that transformative social change will not be won without significant upheaval in workplaces, said Ed Bruno, former director of the United Electrical Radio and Machine Workers of America, and past Southern director for National Nurses United.

“Just think back again about the civil rights movement or the rise of industrial unions or the rise of public sector unions in the states that have collective bargaining,” Bruno said in 2019 amid the Southern Workers Assembly’s campaign to use Medicare for All as a vehicle to organize workers at nonunionized workplaces.

“You’re talking about strikes, sit-downs, sit-down strikes, mass picketing — all of which were illegal. When we think about winning Medicare for All, to think about that divorced from a significant level of action in the workplaces and in communities . . . it’s crazy.”

Labor Is the Missing Piece

Despite national health insurance enjoying broad popular support for almost a century in the United States, a mass movement of millions willing to join together in struggle has so far failed to materialize. Though the connections between labor and national health insurance are plentiful, the single-payer movement is rife with missed opportunities stemming, in part, from an insufficient level of coordination among advocates and workers strong enough to beat back the private forces bent on destroying the so-called lost reform.

The current strategy is primarily focused on legislative efforts, which the history of the single-payer movement shows are unable to match the ability of a powerful grassroots rank-and-file movement to not only mediate conditions on the shop floor but also transform social relations outside the workplace. Parts of a winning coalition operate today, but the critical missing piece to win social reforms is collective power with rank-and-file leadership.

Class struggle is broader than the workplace. It was workers’ “self-emancipation” that won child labor laws, the eight-hour workday, unemployment compensation, Medicare/Medicaid, and workplace health and safety standards. Unlike the majority of wealthy countries, the United States doesn’t have a national health program — a deadly exceptionalism that correlates to American unions’ failure to mobilize workers.

Fain’s call for a militant, national strike in 2028 that connects the UAW’s demands to a broader class perspective represents a clear opportunity to reorient the single-payer movement.

Workplace injuries and deaths in the early twentieth century were endemic and often catalysts for labor uprisings. Protections against worker illness and financial ruin and, later, compulsory health insurance netted support from a cross section of the public, including women suffragists and socialists, along with academics advocating for social welfare reforms.

The movement for national health insurance really picked up steam after World War II, as the UAW and other unions carried forward a sense of renewed concern about social welfare that grew out of the Great Depression. Following labor’s lead and two-thirds of the public, President Harry Truman felt compelled to make “health security for all” a top priority.

Legislation to secure universal health care ultimately stalled in Congress, succumbing to a neoliberal onslaught led by the American Medical Association (AMA). The AMA weaponized respectability by enlisting physicians in a multimillion-dollar smear campaign.

Simultaneously, the conservative bureaucratization of the nation’s large unions severed them from the type of rank-and-file struggles that secured broad social programs prior to the late 1940s. As a result, the weakening of the Left’s ability to mobilize grassroots support for national health insurance quickened the demise of Truman’s proposed legislation by 1950.

“Labor leaders and policy intellectuals believed they could make change from within the system and so did not need the organized activity of union members to back up their efforts,” wrote Beatrix Hoffman, a professor of history at Northern Illinois University. “The lack of rank-and-file participation greatly weakened the cause of union-led health reform as it became associated with ‘labor bosses’ rather than ordinary workers.”

Around the time that Ohio senator Robert A. Taft proclaimed Truman’s health proposal “the most socialistic measure that this Congress has ever had before it,” the lawmaker was putting the finishing touches on a bill that would become the Taft-Hartley Act. The legislation used anti-communist hysteria and witch hunts to gut the unions of many of their progressive rank-and-file leaders, stem the labor tide, and empower private industry to claw back some of the social and economic gains that workers fought for and won during the 1930s and 1940s.

Due to myriad factors, including red-baiting and anti-union legislation that purged the most radical elements of the labor movement, unions shifted their focus away from winning universal social goods. Labor’s pivot toward creating private welfare states for a shrinking portion of the working class hobbled the fight for a national health program in the decades to come.

As labor historian Alan Derickson has noted, “Health security for some thus precluded the possibility of health security for all.”

The fight to secure medical coverage for the elderly during the 1960s presented opportunities for unions to focus renewed attention on social concerns. Under pressure to contain the ballooning costs of retiree health benefits, workers under the UAW and other unions linked arms with civil rights and anti-poverty activists and seniors to secure the passage of Medicare and Medicaid in 1965 over the virulent opposition of the AMA and hospitals.

For most of the last fifty years, the weakness of US labor could be characterized as a narrowing of vision at best and, at worst, collaborationism. By the 1980s, the UAW conceded previous contract wins and settled for labor gains limited to its members rather than connecting their struggle to the broader concerns of the working class.

The inspiring yet short-lived Labor Party of the 1990s challenged the calcified labor movement to leverage its power in the class struggle. The Labor Party platform explicitly called for a national health program and expanded workplace rights. Visionary cofounder Tony Mazzocchi, referring to the universality of single payer, is sometimes credited within the single-payer movement for coining the oft-repeated slogan “everybody in, nobody out.”

Unfortunately, the US struggle for transformative social programs has been marked by means-tested poverty programs that contribute to the abandonment of public goods such as a national health program. Big business, desperate to avoid the overwhelmingly popular Medicare for All, colluded with corporate foot soldiers within the Democratic Party in 2010 to ram through the Affordable Care Act (ACA), a divisive, multitiered poverty program, and portray it as a victory for workers.

Any health care is better than none, but the ACA is analogous to a labor concession contract written by the boss. The limited poverty program further entrenches private insurance, and by linking Medicaid eligibility to state-administered means testing, the ACA deepens class divisions among the public — all while extracting profits from taxpayers.

Barring a few notable exceptions like National Nurses United and the United Electrical, Radio, and Machine Workers of America (UE), support for Medicare for All among the leadership of the country’s largest unions today is mostly relegated to endorsements instead of organizing a supermajority of members to join the cause.

“[Single payer] hasn’t been on the table in fifteen years now,” cautioned Eidlin. “You’re not going to get any kind of groundswell of support for Medicare for All or any other broader social vision unless and until you start putting it back on the table as an item for political debate.”

“Stand Up” for Single Payer

Despite Fain’s class-war rhetoric clearly invigorating both unionized and nonunionized workers, no other unions to date have publicly answered the call to join the UAW on the picket line on May Day, 2028. External threats against organized labor loom over the next four years, from the possibility of a second Donald Trump administration to legal attempts by corporate America to gut the National Labor Relations Act (NLRA).

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. One-off events often fail to build collective power. Rather, it is the process of organizing and building solidarity that is much more important than the turnout for a single event, march, or rally.

The questions at hand are: Will UAW workers see their struggle as part of a wider working-class conflict and reconnect with movements for broad social programs like Medicare for All? And will single-payer supporters link their struggle to them?

Organized labor is the strongest engine of a movement, but there are also inherent contradictions among union leadership who, against workers’ interests, pay fealty to the political oligarchy.

President Joe Biden ran in 2020 on an anti-single-payer platform. He even pledged to veto any Medicare for All legislation that crossed his desk. The UAW’s recent endorsement of Biden makes it clear there is a need for continued class struggle inside and outside the union.

The outcome of the union contract battle at DTNA in North Carolina could be a bellwether for how widespread the call for militant class struggle extends among rank-and-file UAW workers. This, in turn, might help determine whether the auto union is willing to step to the front of social movements, be it on the shop floor or in the community.

It will take more than inspiring rhetoric from labor officials to convince the public that the UAW and other unions are serious about linking their struggles to broader social concerns, and to motivate people to join workers in the fight.

“It is not enough [for the UAW to] sign their names to support Medicare for All,” Jaynes said. “There’s a tendency a lot of times in unions for the leadership to, you know, have lofty political ideas and . . . they’ll pass some resolutions at conventions, but there’s in many cases not enough efforts to mobilize the rank and file, organize the rank and file, and provide political education for people.”

“In order to win public goods, the union movement will have to become a mass movement,” he said.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests — and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector — from the factory worker to the academic, from physicians to food service workers.

Health policy alone does not hold the answer for how to win transformative social change. It is only an indicator of what a movement is able to leverage to win these programs.

“It’s not like we don’t know how to do these policies,” said Eidlin. “It’s really a matter of generating the political force necessary to get these policies in action. You need a broad social coalition and labor needs to be out front.”

Single-payer supporters should link up with rank-and-file campaigns even when they are not specifically focused around Medicare for All. This is not a call for single-payer supporters to show up uninvited, but instead to look to rank-and-file leadership and to actively join their campaigns.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Jonathan Michels is an independent journalist and heath care worker based in Atlanta, Georgia, and a national board member of Physicians for a National Health Program.

Will Cox is a current member of the Southern Workers Assembly and former staff organizer with the National Nurses Organizing Committee.

https://jacobin.com…

In Health Care, Fake Good News Beats Disaster

The Affordable Care Act is far from perfect, we hear again. That’s true. But health insurance with the GOP in power would be far worse, and would cut off the potential for truly effective comprehensive health care financing reform.

A Tsunami of Fake Good News, Healing and Stealing, March 23, 2024, by John Canham-Clyne

Really, the ACA is getting us there! Just give us 500 years!

Since the ACA passed in 2010, the percentage of American adults who have health insurance that actually protects them from financial ruin has barely changed. According to biennial Commonwealth Fund surveys, the percentage of U.S. adults who are insured all year but who aren’t underinsured only grew from 56% to 57% between 2010 and 2022. That pace leads to everyone in the U.S. being fully insured in around 500 years.

The number of people who have been kicked off Medicaid over the past year far outstrips the year-to-year increase of roughly 5 million people enrolled in private Obamacare exchange plans.

It’s also true that several million fewer people were uninsured in 2023 than 2014, so we can expect to hear phrases like “the national uninsured rate reached an all-time low” nearly as often as “record ACA enrollment” for the rest of the year. At the same time, the ACA’s failure to control costs has driven deductibles, copays and coinsurance to record heights in employer-sponsored health insurance, Medicare and many of the ACA exchange plans. This dramatic increase in the number of people who are underinsured largely cancels the gains from the reduction in the uninsured rate.

In the end, what matters about health insurance is whether or not it allows people to get the health care they need. The number of adults ages 19-64 who report skipping at least one of four different types of health care due to cost in the past year is higher now than it was when Obama signed the ACA in 2010. (The four types skipped: 1) Didn’t see Doc for problem, 2) Didn’t fill Rx, 3) Skipped test/treatment/FU, 4) Didn’t get specialist care.)

The weakness of Biden’s opponent can’t turn the ACA into a credibly successful law. Fourteen years after passage, more adults than ever before are skipping treatment or prescriptions because of cost, even though we still spend twice as much as other wealthy nations on “healthcare.” That won’t stop the tsunami of fake good news from washing over us for the next 8 months.

Comment:

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

Maybe the timing doesn’t seem right to talk about the lack of success of the Affordable Care Act just before the presidential elections, but actually the timing probably couldn’t be better.

First of all, ACA has been effective in maintaining a modest level of health care coverage, even if overpriced and inadequate. Biden’s opponent has offered an alternative that is far worse: no standards for fair or good insurance, and likely for most Americans a Hobbesian choice: catastrophic insurance that fails to fund ongoing needs, or a largely self-funded health savings account that would run out when medical catastrophe hits. Voters must realize that we need to elect a Democratic President and a Congress composed of Representatives and Senators with progressive views if we expect to replace our current dysfunctional financing system with one that will work for all of us: a single payer, improved Medicare for All program.

Sure, we don’t want to be taken in by a good guy with fake good news. But it would be far worse to yield to the phony guy with the hidden horrendous news. It is crucial that we, the public, understand what is going on, and (at the risk of repeating ourselves) elect leaders accordingly. A system that will provide all of us access to comprehensive, high quality health care, that each of us can afford through progressive public financing, is exactly what we should be aiming for, and election time is when we have the greatest control over that. Let’s not settle for mediocrity for the next 500 years. Let’s go for the real thing now!

https://healthjusticemonitor.org…

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Private Equity Takeover of Emergency Care = Moral Hazard

Three activist physicians fighting to wrest the harmful control of emergency departments from private equity offer their heartfelt perspectives in this excellent short video.

“I’m A Doctor: Corporate Greed Is Killing Your ER,” 12-minute video, YouTube – More Perfect Union, March 18, 2024

The following are random quotes from physicians in this video:

  • When we could no longer actually take care of the patients the way we would want our grandmothers treated, that’s when we started having problems.
  • Physicians are experiencing burnout and moral injury at unprecedented rates.
  • We have this kind of sacred relationship with patients, and we take an oath to take care of patients. And I think that that really is at odds with the goals of a corporation.
  • They’re not usually in it for the long term (the equity firm). They’re not thinking about, “How do we improve this business long term?” They think about, “How do we make things look better in the short term so we can sell it to somebody else?”
  • In the old group, we were allowed to see what was billed and coded under our names. In this new group, we were not allowed to see any of the billing.
  • This is often how they approach the legislature to say we’re going to innovate! Well, they innovate how to make more money for themselves. They don’t really innovate anything that’s actually helping with society because their secret sauce was gouging patients without any transparency in what’s billed or collected by the physicians.
  • A common theme across comments is that growing financialization in the healthcare industry can force medical professionals to subordinate their medical judgement to corporate decision makers and profit motives at the expense of patient health.
  • The fact that investors or companies are coming into this place, that is just for patients, right? It’s just for people who are in trouble or are scared or dying to come into that space and to say, how can we make money here? Feels to me unholy. It should just be a public utility, just like you should be able to have access to safe drinking water. You should be able to have access to electricity like you should be able to have access to good emergency care whenever you need it.

Comment:

By Don McCanne, M.D.

Although the private equity encroachment on medicine is receiving appropriate publicity these days, this compelling video will help you build the case in your mind as to why we have to end this phenomenon. We must replace the private equity takeover with the system which those of us who chose health care as a career thought we were entering – a universal, affordable, accessible, equitable system that places the patient above all else. We know that this system is attainable through the single payer model. Share the video with a friend, too.

No more corporate greed when we know that is not the route to patient health.

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 Advantage Is Under Fire. What It Means for Your Health—and Wallet.

By Elizabeth O’Brien
MSN, March 20, 2024

Marcia Mantell won’t be eligible for Medicare for a few years yet. But she’s sure of one thing: Pitchmen like William Shatner won’t be luring her into a Medicare Advantage plan.

“You are nickel-and-dimed to death,” says Mantell, 62, a retirement consultant in Plymouth, Mass. Out-of-pocket costs can add up quickly in the plans, she says. And once you’re in, it’s tough to go back to traditional Medicare. “It sounds on TV like you can switch whenever you want. You can’t. It’s a 30-year decision.”

No one has a crystal ball to see how their health will hold up through retirement. But concerns are mounting about Medicare Advantage, also known as Part C—the insurance plans that manage Medicare coverage for more than 30 million people. Some big players in Advantage —notably Humana—are reporting sharply higher costs and lower profits, causing their stocks to fall. If the trends continue, it could translate to ancillary benefit cuts and more denials of services.

Other pressures on Advantage are mounting. Some large hospital chains and medical providers have dropped Advantage plans, citing low payments and administrative hassles. The federal government is scrutinizing Advantage plans over insurance industry practices that are driving up costs. The Biden administration has also taken aim at Advantage marketing—featuring the likes of Shatner and football legend Joe Namath in TV ads—saying it may be misleading consumers.

How this will play out isn’t clear. What’s certain is that consumers are getting caught in a growing battle among the government, healthcare providers, and insurers. With cost pressures rising in the Medicare market, consumers face increasingly complex decisions over which plan to choose, with long-term consequences for their finances and, potentially, their health.

“Everyone involved is feeling cost pressures,” says Ron Mastrogiovanni, CEO of HealthView Services, a retirement healthcare data company. “By next year, they’re going to have to make some changes.”

Just over half of the eligible Medicare population is now enrolled in Advantage, which provides Part A hospital coverage, Part B outpatient coverage, and extras that aren’t offered by traditional Medicare, which is run by the federal government. The plans continue to rake in consumers: From 2023 to 2024, Advantage enrollment is projected to rise by 7%, according to the Biden administration.

For insurers, Advantage has been highly lucrative—but the economics are shifting. Rising healthcare costs are straining the ecosystem of patients, the government, insurers, and medical providers. Labor and other medical costs have risen sharply in the wake of the pandemic, fanning healthcare inflation.

Humana, one of the biggest players in Medicare Advantage plans, has sounded alarms. CEO Bruce Broussard told analysts in January that the whole industry will “possibly reprice” next year, saying the Advantage sector is navigating “unprecedented increases in medical cost trends.” A recent McKinsey & Company report said Advantage was undergoing its biggest shifts in more than two decades.

Current beneficiaries need not worry for now, as any changes to Advantage plans won’t go into effect until 2025, at the earliest. But today’s 65-year-olds weighing Advantage against traditional Medicare don’t have the luxury of time. While the decision isn’t irreversible, switching from Advantage back to traditional Medicare may not be possible if consumers want to add Medigap insurance for uncovered medical expenses, which provides both peace of mind and some assurance that medical costs won’t bankrupt you in retirement.

Advantage plans do look inexpensive. More than 70% of people in plans with prescription drug coverage pay $0 in monthly premiums; the average is just $18.50 a month. Premiums for traditional Medicare are usually costlier, since people typically add Part D drug coverage and often buy Medigap to limit out-of-pocket costs.

Yet, as for-profit entities, Advantage insurers can’t offer the same level of coverage as traditional Medicare plus Medigap. And the cheapest Advantage plans may have to be the most aggressive with care denials, says Louis Imbrogno, chief financial officer of Bariatric Centers of America and an industry consultant. Beneficiaries should ask themselves, “Why can they charge a lot less?”

Enrollees in Advantage still pay the Medicare Part B premium for outpatient services, which is $174.70 a month, or more for high-income beneficiaries. Most people have enough work history to qualify for $0 Part A premiums. Drug benefits are usually included in Advantage, so enrollees don’t need to buy a stand-alone drug plan. Other sweeteners often include free gym memberships and limited dental and vision coverage—none of which is covered under traditional Medicare.

Some studies find that there’s long-term savings for consumers in Advantage plans. According to the Employee Benefit Research Institute, a nonprofit partly funded by the healthcare industry, a couple enrolled in traditional Medicare plus a Medigap plan will need $351,000 to have a 90% chance of covering their medical expenses in retirement. A couple enrolled in Medicare Advantage would need $189,000.

Other analysts see a smaller payoff under Advantage. According to HealthView Services, a 65-year-old male with diabetes would need roughly $109,000 under Advantage versus $120,000 under traditional Medicare plus Medigap for lifetime medical expenses. For a 65-year-old female with cardiovascular disease, Advantage would cost $263,000 versus $315,000 under Medicare/Medigap.

In this analysis, traditional Medicare is so much costlier largely because of Medigap, which can add thousands of dollars a year in premiums. Medicare alone only pays 80% of covered services; patients must pay the rest with no annual caps on out-of-pocket costs. That’s why 41% of beneficiaries add Medigap—which, at its most comprehensive, typically helps cover 100% for tests, doctors visits, and other services after a $240 annual deductible.

Advantage plans also cap out-of-pocket costs—but there are limits. The maximum out-of-pocket allowed for 2024 is $13,300 for combined in- and out-of-network services. Many plans set lower limits, averaging from about $4,800 a year for in-network to $8,600 for combined, according to KFF. Consumers in Advantage plans can’t add Medigap.

Advantage has other drawbacks. A big one is that many plans are HMOs, with limited networks of participating doctors that are subject to change. If a specialist isn’t in-network, the visit generally won’t be covered at all in an HMO, and costs can mount, negating the savings from lower premiums. Plans also frequently require preapproval for certain procedures or tests. And if your care is denied—and/or your health deteriorates, requiring more care and specialists—Advantage can wind up being far costlier than Medicare plus Medigap. “Let’s say they’re not covering something,” Mastrogiovanni says. “You’re responsible.”

Whether the government is saving money with Advantage remains doubtful. Under Advantage, the government pays insurance companies a fixed amount per member based in part on each individual’s health status; under traditional Medicare, the government pays medical providers on a fee-for-service basis. The set payments in Advantage are supposed to serve as an incentive to avoid costly, unnecessary care and offer services that might not fit the Medicare billing system.

Yet some industry practices appear to be bloating costs. The Department of Justice has investigated insurers and charged some with gaming the system to extract higher payments by padding patients’ files with serious diagnoses, even if they aren’t being actively treated. The practice is called “upcoding” and the government is trying to rein it in: The Centers for Medicare and Medicaid Services has estimated that 9.5% of payments to Medicare Advantage organizations are improper, mostly due to upcoding.

The government is also paying more for healthcare overall under Advantage. In 2024, Advantage plans will receive an estimated $88 billion more than what would have been spent under fee-for-service Medicare, according to the Medicare Payment Advisory Commission, an independent Congressional agency that advises Congress on Medicare.

“This has been a highly attractive market for insurers for a long time,” says Gretchen Jacobson, vice president of Medicare at the Commonwealth Fund, a foundation advocating for affordable, quality healthcare.

Insurers, for their part, have long viewed Advantage as a big revenue and profit driver. Advantage has produced the strongest growth of any health-insurance segment, with the highest revenue and earnings per member, according to a recent report by Moody’s.

Covering more than 5.8 million people in Advantage, Humana has the highest exposure to the program, accounting for about 81% of its total premium and services revenue, worth $85.7 billion in revenue last year. The company has built almost its entire business around Advantage, including about 3,500 telemarketing and sales representatives to sell the plans. It also markets Medicare prescription-drug benefits with Walmart.

A Humana spokesperson declined to comment and directed Barron’s to the company’s fourth-quarter earnings call and the website of the Better Medicare Alliance, an advocacy group for Advantage. An industry trade group, AHIP, referred Barron’s to a blog post by Mike Tuffin, CEO of AHIP, who defended Medicare Advantage, saying it has grown in popularity by providing “better care at lower costs.”

Yet insurers are starting to feel squeezed by cost pressures in the Medicare market and other factors, a point noted by Moody’s. Doctor visits have soared since a lull during the pandemic, pushing up insurers’ loss ratios, the portion of premium dollars spent on medical care. Demand trends are also pushing up utilization as the population ages, with some 11,200 baby boomers turning 65 each day.

Access to doctors and hospitals under Advantage may be a casualty, as insurers try to protect profits with skimpier payments to medical providers while providers push back.

Cameron Regional Medical Center, in rural Cameron, Mo., receives 20% less in reimbursements under most of its Advantage plans than it does under traditional Medicare, says Joe Abrutz, the hospital’s administrator. This has been financially devastating, he says, especially as the system’s Advantage population grows relative to patients on traditional Medicare.

Cameron Regional canceled its contracts with Humana and Cigna last year and plans to cancel its contract with Aetna around June or July, Abrutz says. Contracts with UnitedHealthcare and Blue Cross Blue Shield remain intact, he says. Falling revenue means the system has had to shutter two primary-care clinics that serve elderly and low-income patients. “If we can’t be funded properly, you don’t have a choice but to close specialty services you can’t underwrite,” Abrutz says.

Alongside lower payments, hospitals must shoulder higher administrative burdens under Advantage. Plans typically require prior authorization for many procedures outside of primary care, which means more paperwork and potential denials of services. “You’ve got the double whammy of getting paid less by Medicare plans, plus all the demands,” Imbrogno says.

There’s also evidence that Advantage plans are denying coverage for services that traditional Medicare would provide. Among prior-authorization requests that Advantage plans denied, 13% met Medicare coverage rules, according to a 2022 report from the U.S. Department of Health and Human Services Office of Inspector General. One example in the report is an Advantage plan requiring an X-ray before approving more-advanced imaging, which isn’t a criteria under traditional Medicare.

“These Medicare Advantage plans don’t properly care for patients,” Abrutz says. “You have an insurance company on the stock market managing and coordinating the care of a senior citizen.”

The Biden administration has said it is providing plenty of funds to Advantage insurers while trying to curb some of the industry’s bad practices. The administration has proposed a 3.7% increase in payments to insurers from 2024 to 2025, amounting to more than $16 billion. The actual amount will be released by April 1. The administration also aims to rein in upcoding, crack down on “predatory” marketing, and curb excessive compensation to brokers and agents.

TV advertising for Advantage, meanwhile, shows few signs of slowing. A study last year by KFF found 9,500 Medicare Advantage ads aired each day in the fall of 2022 around Medicare’s annual open-enrollment period. “They can’t have all those TV commercials if they’re not making money,” Abrutz says.

The Medicare vs. Advantage Gamble

Will you be better off under Advantage of traditional Medicare? There’s no easy answer.

By law, Advantage plans must cover all Part A hospital and Part B outpatient Medicare services. A 2022 KFF review of studies found no definitive evidence that Advantage or traditional Medicare offered better health outcomes. Patients reported similar rates of satisfaction with each plan. Advantage outperformed on measures such as preventive services, whereas traditional Medicare outperformed on measures such as receiving care in the highest-rated hospitals for cancer care.

The financial trade-offs aren’t clear, either. While Advantage might look cheaper, costs can pile up in the plans, negating the premium savings. And it’s when older adults get sick that the differences may really emerge.

One complication: limited networks of participating doctors and hospitals. In an HMO, a cancer patient might not be able to visit the premier specialist in their region. They might find certain treatments questioned under prior authorization. And Advantage plans tend to charge more at the point of care, including things like a $50 copay for specialists—something typically 100% covered by Medicare plus a comprehensive Medigap plan. A 2020 analysis by KFF found that at least half of Advantage enrollees would pay more than those on traditional Medicare for a five-day hospital stay.

By the time you’re sick, it’s often too late to ditch Advantage and go into Medicare plus Medigap. The only time you are guaranteed the right to purchase Medigap—outside of limited exemptions and a few states with different rules—is when you first enroll in Medicare, commonly around your 65th birthday. Outside that window, Medigap plans may charge more based on your health status or deny coverage altogether for conditions like cancer and poorly controlled diabetes.

The rules keep many people stuck in Advantage. Only 2% of Advantage enrollees switched to traditional Medicare in 2019-20, according to a 2022 study in JAMA Health Forum. Someone in traditional Medicare has the option every fall of switching to Medicare Advantage and, in theory, could also move in the opposite direction. But in practice, “it’s not a two-way street,” says David Lipschutz, associate director of the Center for Medicare Advocacy.

Even some people who sell Advantage plans have said they wouldn’t use them personally. In a focus group conducted by the Commonwealth Fund, most brokers and agents who sold Medicare plans said they personally would choose traditional Medicare with Medigap, believing it offered better coverage and choices than Advantage.

For now, Advantage plans can’t do much to change benefits or impose higher costs, as plans are already set for 2024. But if insurers’ profits continue to be squeezed, they are likely to try to recoup profits by ramping up coverage denials, says Abrutz. They may also reduce reimbursements to doctors and hospitals, and increase monthly premiums.

Another option for insurers is to curtail ancillary benefits, such as free gym memberships. Humana is likely to cut back on some benefits, according to a recent UBS research note. And Humana’s Broussard has warned of ongoing cost pressures. “I don’t know how the industry can take this kind of increase in utilization along with regulatory changes that will continue to persist in 2025 and 2026,” he said in January, noting that “disciplined pricing” will probably result.

As these trends play out, consumers should seek help from a neutral third party when enrolling in Medicare. In the Commonwealth Fund focus group, most insurance brokers and agents reported earning higher commissions for enrolling people in Advantage plans versus Medigap plans. You can find unbiased help through your local State Health Insurance Assistance Program.

Mantell, the retirement consultant, figures it’s better to pay more for Medicare and Medigap than take chances with an Advantage plan that might turn out to be costlier and offer less access to the specialists she and her husband may need as they age. “We are not interested in any restrictions,” she says. “Do you want to be 85 and have to ask for a referral to see a cardiologist because you have chest pain?”

https://www.msn.com…

Medicare for All Explained Podcast: Episode 109

Some Really Good Reasons Why We Need Medicare For All

March 15, 2024

Podcast host Joe Sparks reiterates some of the major benefits of single-payer reform. Improved Medicare for All would:

  • Save money by reducing administrative costs
  • Provide better and more comprehensive care
  • Prevent needed hospitals from closing
  • Increase disposable income for almost all Americans
  • Save tens of thousands of lives per year

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

https://medicareforallexplained.podbean.com

The Burdens of Prior Authorization

The NY Times posted a powerful video editorial on the major distraction, high cost, doctor-frustrating, and patient-harming effects of rising prior authorization requirements by private health insurers.

Denying Your Health Care Is Big Business in America, On YouTube, NYT Opinion Video, March 14, 2024, Video by Alexander Stockton

Doctors are often required to get insurance permission before providing medical care. This process is called prior authorization and it can be used by profit-seeking insurance companies to create intentional barriers between patients and the health care they need.

At best, it’s just a minor bureaucratic headache. At worst, people have died.

Prior authorization has been around for decades, but doctors say its use has increased in recent years and now rank it as one of the top issues in health care.

To produce the Opinion Video, we spoke to more than 50 doctors and patients. They shared horror stories …

Prior authorization has come under intense scrutiny in Congress in the past few years, but bipartisan proposals have repeatedly stalled. Under public pressure, some insurance companies — like United Healthcare and Cigna — have said they would reduce the use of prior authorization. And in January, the Biden administration finalized a plan to put limited guardrails around this practice. But doctors say that these efforts only scratch the surface and should go further.

This issue is ultimately about the role of insurance companies in American health care: Should they have more power than your doctor to decide what’s medically best for you?

From the video:

… An absurd process has infiltrated American Healthcare. It’s called prior authorization. Here’s how it works. Before your doctor provides a treatment, your insurance requires them to prove it’s necessary. This is often a time-consuming process that can cause dangerous delays.  …

When your prior authorization is denied, you have three options. You could just pay out of pocket, but healthcare is so ridiculously expensive that that’s not realistic. You can give up. That’s what happens up to 80% of the time: a win for your insurance company. Or your doctor can go to bat for you.

When our prior authorizations get denied we have to do what’s called a peer-to-peer. A peer-to-peer is supposed to a phone call where you call somebody who is your peer to justify the treatment that you want to deliver. I’m a pediatrician and sometimes I’ll end up talking to a neurologist … people who couldn’t pronounce the names of the drugs I was trying to prescribe. Often times it’s not even a physician. Now imagine you have to do that five to 10 times a day. What’s even more ridiculous about this whole process is that after we go through all of this if you’re really a determined provider you’ll probably get your drug or your procedure authorized.

… By one estimate the US spends about $35 billion a year [HJM: $100 per person] on the administrative costs of prior authorization. These resources could be devoted to Patient Care. …

In many countries these tough ethical decisions about what is covered are made by governments, not for-profit insurance companies. The government should abolish prior authorization or at the very least reform it. Sen. Curt VanderWall: My goal with Senate Bill 247 is to reform the prior authorization process. House Bill 3459 creates a streamlined prior authorization process known as “gold carding.” … Doctors who have successfully obtained prior authorizations … are exempt from needing to obtain them again. All states and the federal government should pass laws like these. Your insurance should not be a barrier between you and the healthcare you need.

Comment:

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

In my opinion, thoughtful and well-circumscribed prior authorization has an appropriate role in medicine. It can work with other methods (e.g., training and peer review) to advance effective and quality care, weeding out clinically unnecessary services. As a health economist, I even understand its careful use to help wisely and equitably spend health resources.

Yet that’s not what’s happening in the US currently, according to various reports, both anecdotal and quantitative. The NY Times video effectively captures the burdens that prior authorization increasingly imposes on doctors (who spend far too much time pleading with insurers) and patients (whose care may be delayed and denied).

What’s the difference between ideal and problematic use of prior authorization? To paraphrase a famous political slogan, “It’s the profits, stupid.” When the financial well-being of insurance company executives and shareholders is conflated with fairness and efficiency in medicine, the balance will surely tilt away from optimization of health care for patients.

As the video says, other countries get it right. We can too, with single payer.

https://healthjusticemonitor.org…

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Private Equity vs. Health Care

Private equity in health care is causing widespread problems. Regulation is not the solution. Comprehensive reform with a lead public role is.

Private Equity-Acquired Physician Practices and Market Penetration Increased Substantially. 2012-21, Health Affairs, March 2024, by Ola Abdelhadi, et al.

Private equity (PE) firms have consistently shown an upward trend and an increased interest in acquiring various medical specialties within physician practices. Our analysis revealed evidence of a recent increase in PE market penetration at the physician level across multiple specialties, particularly gastroenterology, dermatology, and urology. We found that specialties such as primary care, obstetrics-gynecology, radiology, orthopedics, and oncology also showed considerable increases from 2012 to 2021. Acquisition of these practices may be attractive to PE firms because of the fragmentation of the practices and increasing patient demands as the result of an aging population and rising private insurance coverage.

This upsurge in acquisitions, particularly after 2010, has raised concerns about their impact on PE market penetration. Previous studies showed an increase in PE acquisitions of physician practices between 2013 and 2016, resulting in expansion and higher prices without any impact on the quality of health care services. Our findings indicate that in specific local markets, PE firms hold market shares exceeding 30 percent and 50 percent, sometimes by a significant margin. This trend raises concerns about its potential impact on competition, patient care, and prices in those local markets.

PE firms tend to prioritize short-term profit maximization over long term investment in patient care and infrastructure, implement aggressive acquisition strategies that may curtail patient choice and competition, use complex financial structures and leverage to finance acquisitions, and possess limited experience in the health care industry – all of which may lead to difficulties in managing and enhancing patient care.

The findings raise concerns about competition and call for closer scrutiny by the Federal Trade Commission, state regulators, and policy makers.

Private Capital, Public Impact: An FTC Workshop on Private Equity in Health Care, Video here, March 5, 2024 

Opening Remarks:

  • Lina M. Khan, Chair, Federal Trade Commission
  • Jonathan Kanter, Asst. Attorney General of the Antitrust Division, Dept. of Justice
  • Christi A. Grimm, Inspector General, Dept. of Health and Human Services
  • Jonathan Blum, Principal Dep. Administrator & COO, Centers for Medicare & Medicaid Services

Comment:

By Patty Harvey

The March 5 webinar on private equity et al. in health care carefully enumerated the drawbacks and dangers of privatized health care in the U.S. All of this was duly documented and verified by the speakers as well as by personal anecdotes. We all have had brushes with the downsides of a health-care system that prioritizes profit and the experiences of Atty General of R.I., Peter Neronha, were especially revelatory as he described endless battles against phalanxes of high powered and richly funded attorneys protecting the private equity juggernaut. He observes, briefly in conclusion, that ‘all private equity should be kept a thousand miles from health care.’ When panelists were asked for real remedies for this worrisome privatization scourge, the band aids proposed were: “increase transparency, close loopholes and levy fines for malfeasance.” What is strange is that the obvious was never suggested even while it was implied by Mr. Neronha: that no matter what regulations, punishments or vigilance is brought to profiteering, those who stand to profit will never cease to find ways to accomplish their goal. Given this reality, why are we ignoring the obvious solution; namely, a healthcare system that is publicly provided by a single payer, especially a governmental agency, that takes no profit and streamlines in its singularity all administrative activity, that would, at the same time, obviate the need and role for these predatory profit seekers? We don’t allow a profit motive in many of our public institutions—police, fire, public education, libraries and many more operate for the common good. How much more crucial to universal human need is the need for life-saving medical support? Why do we allow profit-seeking middlemen to take over this job, when the result is universally lower quality and higher cost? We need to petition the CMS to adopt pilot programs that explore the implementation of a universal, guaranteed, single-payer, not-for-profit healthcare system instead of grinding us down with these bogus, dangerous and destructive privatization programs. The March 5 webinar exposed many important realities. The neglect was to ignore the most obvious solution.

Comment:

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

The negative consequences of the role of private equity in our health system are finally receiving much-needed attention. We can now see why health care costs have been increasing without the improvement in quality and expanded coverage that we would expect for what we spend.

What is sad is that Arnold Relman warned us so long ago about the medical-industrial complex, and we did nothing. Then, more recently, individuals such as Laura Katz Olson in her book “Ethically Challenged” sounded the alarm about private equity (HJM post), and we still haven’t done what is needed to correct these deficiencies.

While we dither, afraid of a core public role in health care, the private equity market is exploding, lucrative for investors and deleterious for health care providers and, above all, patients.

The US government workshop convened on March 5th focused attention on this profound problem. Yet, as Patty Harvey’s comment so poignantly highlights, there was no mention of the real solutions — a “universal, guaranteed, single-payer, not-for-profit healthcare system.”

Although single payer financing would resolve many issues in ensuring access to affordable health care for all, the issue of provider ownership must also be addressed to avoid the adverse consequences caused by private equity. Wouldn’t it be better for doctors and hospitals to be publicly owned wherein they deliver health care to patients without profits for passive investors? Everyone can receive care from public-spirited providers, without accruing medical debt, fairly funded by progressive taxes.

The article authors and webinar presenters argue for transparency and regulation of the private owners. But with public ownership, transparency would be automatic since we would all be owners.

The authors correctly state that rising private insurance coverage has made private health care system purchases more attractive to private equity. Yet private insurance itself has been a major contributor to our health care inequities and dysfunctions – one more compelling reason to switch to single payer.

Suppose we listen to those people who say that we don’t want the government involved in ownership. Who would pay the outrageous purchase prices that private equity firms want when they sell entities that they have drained of value? Where in the private sector is the money going to come from? Inevitably it would still be some form of private equity, with or without health care providers … buying money opportunities, not health care.

Regulators alone are not going to save us from the billionaire private equity predators. The only way we are going to take health care back is for all of us to take public ownership together. No? Then read the full Health Affairs article and listen to the workshop to understand what to expect in the near future – venture capitalists have all the money and we have a seriously underperforming, dysfunctional mess of a health care system. Not that we aren’t already well on our way there.

https://healthjusticemonitor.org…

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Medicare Advantage Worsens Coverage

A national survey of Medicare beneficiaries quantifies the coverage experience. Bottom line: Medicare Advantage (MA) underperforms traditional Medicare for most metrics. MA has more care delays and financial barriers, and similar care coordination burden, despite massive overpayment of MA plans.

What Do Medicare Beneficiaries Value About Their Coverage?, Findings from the Commonwealth Fund 2024 Value of Medicare Survey, February 22, 2024, by Gretchen Jacobson, et al.

Survey Highlights:

  • Whether enrolled in Medicare Advantage or traditional Medicare, about two in three beneficiaries overall said their coverage has fully met their expectations. Those who said it fell short of expectations pointed to a lack of coverage for needed services, high costs, or uncertainty about what benefits are covered.
  • Larger shares of beneficiaries in MA plans than in traditional Medicare reported they experienced delays in getting care because of the need to obtain prior approval (22% vs. 13%) and couldn’t afford care because of copayments or deductibles (12% vs. 7%). By other metrics, access to needed health care was similar. For example, more than a third of beneficiaries in each type of Medicare coverage said they had to wait over a month to see a doctor.
  • Three in five beneficiaries in MA plans and one-quarter in traditional Medicare said they were asked to undergo a health assessment, which most frequently resulted in a discussion with their doctor. Few said it resulted in any changes to their care plan or in more services or benefits being offered.
  • Seven in 10 beneficiaries in MA said they used some of their plan’s supplemental benefits in the past year; three in 10 did not use any. Four in 10 reported using their dental or vision benefits or an allowance for over-the-counter medications.

Administrative Burdens: Getting medical bills paid by their Medicare plan is one of the often time-consuming administrative tasks that beneficiaries must handle themselves. A somewhat larger share of beneficiaries in MA plans compared to traditional Medicare reported a delay in getting health care in the past 12 months because of administrative paperwork (9% vs. 6%; data not shown) or difficulty obtaining approval from their Medicare coverage (15% vs. 9%; data not shown).

More dual-eligible beneficiaries in Medicare Advantage than in traditional Medicare said their coverage has fully met their expectations.

Comment:

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

Talking with Medicare beneficiaries is the best way to assess their coverage experience. What we learn is that two-thirds of enrollees are happy with coverage, but one third are dissatisfied due to coverage gaps, costs, and benefit uncertainty.

Importantly, Medicare Advantage (MA) beneficiaries are more likely to experience care delays due to prior approvals and can’t afford care due to out-of-pocket costs. That is, access to care is worse in MA than in traditional Medicare (TM), despite overpayments of about $100 billion per year.

MA enrollees do, however, get more health assessments – 60% vs 25% in TM. Why? Because that’s a tactic that MA plans use to add diagnostic codes to game risk adjusted payments (discussed in our most recent HJM). Typically without “changes to their care plan or more services or benefits”.

Supplemental benefits in MA are used by most, though any particular benefit is not used much.

Being in MA increasing the likelihood of care delay due to paperwork and approvals. Strikingly, despite the claim that MA plans integrate care, MA enrollees are just as likely as TM enrollees to coordinate their own care.

One finding favors MA: Among Medicaid-Medicare dual eligibles (typically with complex medical issues), those in MA are a bit happier with coverage than those in TM. Not sure what that’s about, and no explanation is offered.

Overall, negative coverage value for the huge added expense of MA. Time to switch to an (improved) traditional Medicare for All – single payer.

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.