PNHP

US Hospital Money Machine

US Hospital Money Machine

Summary: US hospitals use aggressive business models (mergers, high prices, & marketing of lucrative services) to drive up revenues. For-profit hospitals benefit investors, but even not-for-profits act similarly, with huge financial rewards for participants. Single payer’s hospital global budgeting would remove these perverse incentives.

Hospital Billing Is a Crime Against American Patients, The American Prospect, November 22, 2022, by Robert Kuttner

Most hospitals in the U.S. are either for-profits, or nominal nonprofits like large teaching hospitals that behave just like for-profits. Their goal is to maximize market share, particularly for the most lucrative specialized procedures. That means they spend a great deal of capital, not just on acquisitions but on construction of new facilities (that may be redundant in many cities) and on new costly equipment.

U.S. hospitals have triple the capital costs of Europe’s hospitals. Meanwhile, every major European nation not only spends far less on health care but has much better outcomes in terms of every major health indicator.

Medicare could save taxpayers a lot of money. Why are they so timid? Because hospitals in many areas are the largest and most politically powerful local employers, even more so when they are teaching hospitals connected to universities.

One of the many regulatory failures of antitrust in the U.S. is the nearly complete failure to challenge hospital mergers and acquisitions, which have created monopoly power and degraded services in city after city. Even worse, many of these merger binges are by hospital systems that are nominal nonprofits.

There is no direct price regulation in the U.S., so hospitals are free to charge what they think the market will bear.

Hospitals also overuse specialists, who can bill at higher rates.

Executive pay is also exorbitant.

A variety of market-friendly techniques were devised to contain costs. Hospitals proved expert at gaming all of them.

Until recently, advocates of single-payer health care have focused on comprehensive coverage but less so on the abuses of profit-maximizing medicine. If we went to Medicare for All but did not reform these billing practices and did not end the system of profit-maximizing medicine entirely, these excess costs would simply be piled onto taxpayers.

Rep. Pramila Jayapal’s current Medicare for All bill does best at addressing these abuses, and Bernie Sanders’s latest version is more attuned to them than his earlier bills.

Under Jayapal’s bill, co-sponsored by about half of the House Democratic caucus, the system would keep some elements of fee-for-service medicine and diagnosis-related coding, but hospitals would operate under “global” budgets. That is, they would receive an annual flat sum from the government that would be adjusted regularly to reflect caseloads. Medical education—one of the ways that teaching hospitals pad bills—would be its own separate budget item. Capital outlays and staffing ratios would be regulated. Incentive compensation aimed at gaming the system would be prohibited. There would be much greater emphasis on primary care.

This legislation, which merely reflects common practices in most European nations, is at the outer fringe of what is even debated in the U.S. It is a reminder of how inefficient as well as unjust is market-led medicine, and how incremental reforms can never repair our broken health system.

Comment:

By Don McCanne, M.D.

Although we have the most expensive health care system in the world, it performs very poorly by international standards. We have far too many who are uninsured or underinsured and thus suffer financial hardship, and our system has too many features designed to direct health care dollars to the wealthy rather than to the patients where the need is so great. This article by Robert Kuttner demonstrates that another defect is in one of the most basic elements of our health care system: our hospitals!

Hospitals have not escaped much of the fragmented and dysfunctional design defects that characterize our health care system. As a glaring example, our nominally nonprofit hospitals, which should be dedicated to providing health care to the most needy, frequently engage in activities that make the rich (e.g., prodigiously paid CEOs and procedural specialists) richer as unmet community care needs should make us cry out for universal insurance.

Yet where are our reform activities directed? Our current government, which is supposedly more progressive than the alternative, has been busy converting our public Medicare program into private insurance plans, via heavily marketed but optional Medicare Advantage and now involuntary Direct Contracting through the REACH program. Meantime, ownership of the actual health delivery system is passing to private investors through private equity and other innovative business constructs designed to siphon off the massive pool of health care dollars that we have but are not using in the high performance system that our nation deserves.

What is wrong with us? For decades we have known that a well-designed single payer system, using an improved version of Medicare, would serve all of us well. As we have stalled and deferred, allowing inadequate, dysfunctional, incremental measures to substitute for reform, we have allowed our health care system to feed the injustice of wealth inequities such that we now have a much greater legislative problem than merely establishing a universal public health insurance program.

That makes it all the more urgent to act now. The shift of wealth to the top is a rapidly accelerating process. We are not talking about some vague population in the future. We are talking about our grandchildren and even our children. Look around at the medical needs that our aging friends face. How can we be so callous as to not ensure that those needs will be met for all of us in the future. Now is when we have to act! Dammit, now!

http://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.

Corporations Are Thankful for US Health Care

Summary: UnitedHealth proposes a $13 billion acquisition of other insurers’ billing data, which they swear they won’t use for business purposes. Hospitals farm out unpaid patient bills to high interest lenders owned by private equity firms and banks. Once again, untrammeled profit-seeking hurts patients.

What Will UnitedHealth’s New Trove of Claims Data Mean for Consumers?, ProPublica, November 16, 2022, by Cezary Podkul

Data from Change [a medical claims processing company] could yield “improved medical policy and benefit design” for UnitedHealthcare, the UnitedHealth deal team wrote in a memo. The data could also help UnitedHealthcare track the pricing of medical procedures and expand insurance underwriting. There was just one problem: Using Change’s data in some of these ways could raise “antitrust concerns,” according to an internal UnitedHealth document. 


UnitedHealth announced plans in January 2021 to buy Change for $13 billion. 


[At antitrust trial, the judge accepted] UnitedHealth’s claims that the company would never do such a thing. 


“it’s clear that they are finding ways to use data to make money,” Prof. Fuse Brown said. That applies to the Change Healthcare deal, she said: “You have to wonder: What is the value proposition? Why is United spending so much money to buy this company?”


Wall Street seems to have viewed UnitedHealth’s recent ambitions through that prism. Since the merger was first announced on Jan. 6, 2021, UnitedHealth’s stock has far outpaced the broader stock market, rising 46% vs. 17% for the health care sector and 7% for the S&P 500. JPMorgan Chase analysts predicted in a research note that insights from Change’s data will benefit UnitedHealth’s insurance arm as well as Optum’s other customers. Analysts at Deutsche Bank 
 called UnitedHealth’s courtroom victory a “positive leading indicator” for more consolidation in the health care sector.

How Banks and Private Equity Cash In When Patients Can’t Pay Their Medical Bills, KHN, November 17, 2022, by Noam N. Levey and Aneri Pattani

Patients at North Carolina-based Atrium Health get what looks like an enticing pitch when they go to the nonprofit hospital system’s website: a payment plan from lender AccessOne. The plans offer “easy ways to make monthly payments” on medical bills, the website says. You don’t need good credit to get a loan. Everyone is approved. Nothing is reported to credit agencies
.

As Americans are overwhelmed with medical bills, patient financing is now a multibillion-dollar business, with private equity and big banks lined up to cash in when patients and their families can’t pay for care. By one estimate from research firm IBISWorld, profit margins top 29% in the patient financing industry, seven times what is considered a solid hospital margin. 


Patients enrolled in a CareCredit card from Synchrony, the nation’s leading medical lender, face a nearly 27% interest rate if they fail to pay off their loan during a zero-interest promotional period. The high rate hits about 1 in 5 borrowers, according to the company
.

In February 2020, records show, just 9% of UNC patients in an AccessOne plan were in a loan with the highest interest rate of 13%. Two years later, 46% were in such a plan. Overall, at any given time more than 100,000 UNC Health patients finance through AccessOne.

Comment:

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

As I sit at my son’s house in Colorado, sated by a delicious Thanksgiving feast, I’m extremely thankful for a loving and healthy family, and the recent improvement in US political prospects.

The health news that caught my attention elicited a more ambivalent thought: US healthcare is a playground for corporations, rife with opportunities to exercise business prowess – often at the expense of beneficiaries.

What should a health care system do? IMO: offer easy access to high quality care, with no financial barriers or burdens. Profits must not displace care. We are, of course, falling far short of this ideal. The news provides two clear examples.

UnitedHealth – the largest private insurer, with 15% of the national market – is trying to purchase the company that handles billing (claims processing) for many insurers. Why would they spend $13 billion for this? Company analysts told the CEO that they could use the claims data to track provider prices and strengthen underwriting (predicting medical “losses”). This raised anti-trust concerns and led to a trial, in which UH promised not to do the very actions used to justify the acquisition. They won; the government is appealing.

What’s lost in these deliberations is that the aim of anti-trust regulation – helping consumers – is futile when the very fact of a for-profit insurance industry results in severe harm to patients.

The other story is about hospital tactics to offload management of patient debt onto credit companies owned by private equity firms. One large company structures interest rates to offer 0% for debtors paying the highest amounts most consistently, and 13% for those who can’t accomplish that. Which means that the least financially able pay extra by one-third, $2,500 in interest on top of a $7,000 original debt. Some lenders charge more than 25% if payments are missed. This loansharking (that’s what it is) exacerbates the underlying problem of pervasive medical debt. And the care credit business generates 29% profits.

I’ll reserve my deepest thanks for the day that the US follows the example of dozens of other countries which provide universal comprehensive care with no profit-taking, saving money and lives.

http://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.

Healthcare and Labor advocates demand Cigna put Care Over Cost and cover critical treatment

Health care and Labor advocates deliver more than 3,000 petition signatures demanding Cigna live up to its promise

By Tim Rowden
St. Louis / Southern Illinois Labor Tribune, November 21, 2022

Dozens of health care and Labor advocates – including representative from Painters District Council 58 and Operating Engineers Local 148 – jammed the sidewalk surrounding Bemiston Tower in Clayton, Mo., Nov. 11 to launch of Missouri Jobs with Justice’s Care Over Cost initiative connecting health care policy holders stiffed by their insurance companies to demand private insurers provide the coverage they promised.

Bemiston Tower allegedly houses Cigna insurance’s St. Louis office. It’s hard to say for certain, however, as aggrieved policyholders and advocates were prevented from entering the building to deliver more than 3,000 petition signatures demanding they cover Springfield, Mo. resident Mark Hall’s ulcerative colitis medication.

Cigna is not alone among private insurance companies prioritizing profit over coverage for necessary health care expenses.

St. Louis

Andre Smith, a St. Louis resident and student at Rockhurst University, shared his story of facing crippling debt after receiving a surprise $15,000 bill from Blue Cross Blue Shield (BCBS) of Kansas City.

“Health insurance companies rake in billions of dollars of profits off our premiums and then turn around and deny services and medication to their customers” said Smith. “I know as an individual, I am powerless to stop them – BCBS has shown me that by ignoring my pleas.

“When I enrolled at Rockhurst in the fall of 2021, I got access to health insurance with Blue Cross Blue Shield, something I was very thankful for, but also a requirement to attend the institution. I assumed with insurance I could get access to the care that I needed. Isn’t that the entire point? But sadly, at 19 years old, I learned that that is not what health insurance companies do. Instead of helping me when I became sick, I was stuck with an over $15,000 surprise bill I cannot afford just for trying to use the insurance. Fifteen-thousand-dollars for a 19-year-old college student is a life-crippling amount of debt.”

Smith learned about the Care Over Cost campaign of Missouri Jobs with Justice and was on hand Nov. 11 for its launch.

The Jobs with Justice Care Over Cost initiative seeks to connect people like Smith and Hall and build a movement that demands insurance companies prioritize care over profits.

After months of trying to reach BCBS, Smith spoke last month as part of a national Care Over Cost event.

“Right after I spoke, they reached out to me and I am hopeful they will finally agree to cover the services I was provided while I was insured with them.”

Springfield

In Springfield, advocates stood in solidarity with Mark Hall and his wife Callie Gibson as the couple shared just a bit of their healthcare story – and the ongoing struggle of fighting Cigna to simply cover the care Mark needs to manage his chronic illness.

“I was diagnosed with ulcerative colitis when I was 20. Essentially my digestive tract gets inflamed, which causes sores and bleeding from top to bottom,” said Hall. “After months and months of working with my care team, I found a treatment that worked – and worked well for more than a decade – my last colonoscopy indicated I was in remission.

“Last summer, my employer-provided health insurance communicated that my medication was no longer the preferred drug and that I’d be switched. My doctor appealed this decision, but was denied. We began the new drug regimen, and my symptoms returned within four weeks.”

“Mark has been paying into Cigna for more than three years and is being denied the medication that we know works,” said Mark’s wife, Callie Gibson. “We spend MULTIPLE hours on the phone with the hospital and the insurance company EVERY WEEK – which we shouldn’t have to do.

“We’re sharing our story now because this is not how healthcare should work – and not how people should be treated. Cigna made BILLIONS of dollars last year – and this year – in part by making sure people don’t know what their options are, denying care, countering doctors’ orders, all the while we all get sicker, and the bills pile up.”

‘Good health insurance’

“Many of us think we are protected by ‘good health insurance.’ We only learn how companies win and patients lose once we become ill,” said Dr. Judith Dasovich, MD, FACP.

“As Mark Hall’s situation illustrates, private insurance companies are not prioritizing care. What are they prioritizing? Profit. In 2021, Cigna made $5.4 billion in profit. In the first nine months of 2022, they made $5.5 billion, more than all of 2021.”

‘Mad as hell’

“Most doctors I know are like me,” said Dr. Ed Weisbart, a family physician, chair of the Missouri chapter of Physicians for a National Health Program and former Chief Medical Officer for Express Scripts before it was purchased by Cigna. “We love helping our patients, but we are mad as hell that they have to go through this again and again and again.

“Think about it – Mark and his employer are paying Cigna to not give him the medication he needs to be healthy. That may be a great deal for Cigna and its investors, but it’s morally reprehensible, infuriating, and often deadly.”

https://labortribune.com…

Private Equity Termites

Summary: Private equity is consuming US health care from the inside out, weakening its structure and strength, enriching investors at the expense of patient care and patients. Incremental health reforms have failed. It’s time to move past political barriers to achieve consensus on real reform.

Termites in the House of Health Care, Milbank Quarterly, November 14, 2022, by John E. McDonough

Private equity firms are financial termites devouring the woodwork and foundations of the US health care system. As Laura Katz Olson documents in her new book, Ethically Challenged: Private Equity Storms US Health Care, “PE firms are gobbling up physician and dental practices; homecare and hospital agencies; substance abuse, eating disorder, and autism services; urgent care facilities; and emergency medical transportation.”

Just as termites are characterized as “some of the most successful insects on earth,” private equity has become a growing and diversified part of the American health care economy. Demonstrated results of private equity ownership include higher patient mortality, higher patient costs, fewer jobs, poorer quality, and closed facilities.

Dr. Arnold Relman, late editor of the New England Journal of Medicine, presciently wrote in 1980 of an emerging “medical-industrial complex.” As “vast new funds were moving into medical care,” wrote Relman, “the health care system was rapidly changing from a professional service primarily devoted to the care of the sick into a lucrative and competitive marketplace for investors and investor-owned corporations.”

Private equity is not the only force in US health care needing reform. Health insurers, hospitals, drug makers, pharmacies, and others have placed financial interests ahead of patient needs.  No other part of the system, though, is designed so thoroughly to maximize short-term financial benefit to shareholders above all else. Action is overdue to stop the rot.

John E McDonough is a Professor of Practice at the Harvard T. H. Chan School of Public Health

Comment:

By Don McCanne, M.D.

John McDonough has always supported universal health care coverage, but has recognized the political barriers, and thus was an active supporter of first the Massachusetts health reform law and then the Affordable Care Act as incremental approaches to reform.

As recent as February 2020, he wrote an article in Health Affairs on why Medicare for All remains a virtual political impossibility. Health Affairs published my comment in response making the point that “when you have the right policy and the politics are wrong, you don’t change the policy to comply with the dysfunctional politics, you change the politics instead.”

In the meantime, our quest for health care justice through a universal, publicly funded, equitable single payer financing model labeled Medicare for All has evolved into an inadequate approach as we stated in The Nation, as private corporate control takes over much of health care. Laura Katz Olson in her book, “Ethically Challenged” explains how private equity is stripping the health care system of its assets – the “termites” that McDonough cites. Medicare is increasingly becoming privatized as Medicare Advantage plans divert health care dollars to their own investors and ACO REACH threatens a corporate exploitation of traditional Medicare.

Well, where does this lead us? The incremental approaches have been a disaster – perpetuating profound inequities in health care, with far too many uninsured and underinsured. The inattention to public financing has allowed health care dollars to be diverted to wealthy investors, leaving tens of millions without means of paying for the health care that they need.

We need to redesign the system so that it works on both fronts: an equitable financing system for all, and devoid of the “termites.” Then we need to intensively publicize our results such that essentially all rational citizens will recognize the clear superiority of the public financing solution to our health care quagmire. Even John McDonough should agree that it is time to overcome political hurdles, and adopt the best policy for all of America.

http://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.

Health Insurance News Triplet: DĂ©jĂ  Vu & Powerfully True

Summary: Three recurring health insurance news themes are so potent, they should become a meme: 1) Private insurers pursue profit via manipulation; 2) Even insured patients bear massive cost burdens; and 3) There’s strong popular support for fundamental reform. Let’s roll with this meme!

How Medicare Advantage Scams Seniors | Opinion, Newsweek, Nov. 15, 2022, by Rep. Jan Schakowsky and Wendell Potter

Where billions of dollars flow, deceptive actors follow. And nowhere does deception run deeper than how health insurers lure seniors into Medicare Advantage plans—only to leave many retirees struggling to cover their out-of-pocket requirements when their incomes are their lowest. 


Medicare Advantage is a health insurance program in which private health insurers are reimbursed generously by the federal government for providing insurance coverage, sometimes with additional benefits, to retired Americans. This incentivizes insurers to sign up as many elderly folks as they can. While many Medicare Advantage plans provide some coverage for dental, vision and hearing and discounts on gym memberships, their ads obscure the often-life-threatening restrictions and bank-account draining demands that are common in Medicare Advantage plans
.

One in four Medicare Advantage plans are being falsely advertised. 


In just one year, [diagnostic] upcoding accounted for $12 billion in additional payments to Medicare Advantage plans.

Financial Outcomes After Traumatic Injury Among Working-Age US Adults With Commercial Insurance, JAMA Health Forum, Nov. 11, 2022, by Scott JW et al.

Results: The 3165 working-age adults in the postinjury cohort were similar demographically to the 2223 patients in the comparison [pre-injury] cohort. The postinjury cohort had a 23% higher likelihood of having medical debt in collections (754 [23.8%] vs 429 [19.3%]; a 70% higher amount of medical debt in collections ($2087 vs $1227), and a 110% higher bankruptcy rate (39 [1.2%] vs 13 [0.6%]). No significant differences were found regarding credit scores or nonmedical debt in collections.

Oregon Voters Approve Ballot Measure To Recognize Health Care As A Human Right, DailyWire.com, Nov. 15, 2022, by Dillon Burroughs

Oregon voters have approved [50.6%] a measure that recognizes health care as a human right.

“It is the obligation of the state to ensure that every resident of Oregon has access to cost-effective, clinically appropriate and affordable health care as a fundamental right,” the amendment reads.

Comment:

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

Over the 1.5 years of HJM posts, patterns emerge. As I was perusing topics for today’s blog, I encountered a strikingly familiar trio of important stories: private insurers mislead, beneficiaries become indebted, and people want real change. This trifecta is a meme.

The Newsweek op-ed by Schakowsky and Potter highlights how private insurers – who run Medicare Advantage plans – mislead beneficiaries with overblown promises of coverage and bilk the government of tens of billions a year with exaggerated diagnoses. This is a persuasive synthesis of recently reported misbehavior by Medicare Advantage, the predominant source of growth for private insurers. ACO REACH in traditional Medicare poses similar privatization risks.

The JAMA Health Forum article reveals the high medical debt and bankruptcies borne by privately insured patients who experience traumatic injury. This is a compelling clinical example of data on the general population: 40% of adults have medical debt (average $2,500) and there are >250,000 annual medical bankruptcies.

The news from Oregon confirms that voters support a fundamental commitment to health care justice. The margin was narrow, and operational details were omitted, but the statement of values aligns with polling that indicates two-thirds support for government funding of health care.

Insurer profits, patient debt, and a popular craving for real reform: this is where we are in 2022.

Memes are motivating. Let’s use this one to help us achieve the change that would make it anachronistic.

http://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 may be a scam

By Ellen Kaczmarek, M.D.
Asheville (N.C.) Citizen-Times, November 16, 2022

Thanks to an Oct. 9 New York Times article, attention has been drawn to the Medicare Advantage (MA) scam and we are better informed about where our Medicare dollars go.

We have seen how MA insurers persuade otherwise intelligent seniors to sign up by offering freebies like gym memberships, zero premiums and discounts on hearing aids, eyeglasses and dental care. We all know there is no free lunch, and it’s now obvious that this swag is paid for by bilking taxpayer-funded Medicare into giving the for-profit MA companies much more than they need to provide health care while they restrict access to many out-of-network doctors and hospitals. Those insurance companies make you look “sicker” on paper by a process called “upcoding” to have Medicare pay them more for your medical care (which you don’t get). The insurers keep what is not spent on your care.

And now there’s a new threat to the entire Medicare program, created in the last months of the Trump administration. Initially called Direct Contracting but renamed REACH (Realizing Equity, Access, and Community Health), this insidious program aims to completely privatize Medicare by 2030.

Wall Street investors are excited by the prospect of profits approaching 30 percent, which can come only by further cheating the government and withholding needed health care from seniors. The program encourages insurers to grow their volume by allowing them to sign up seniors without their permission. The only way seniors can exit the program is by changing primary care physicians, which most are extremely reluctant to do.

The REACH program requires no further Congressional approval. The only way to stop it is pressure from the Medicare recipients. Find out more at ProtectMedicare.net. Call the White House directly to demand an end to the REACH money-grab from the Medicare fund.

full article:
https://pnhp.org…

Medicare for All Explained Podcast: Episode 89

The Security Threat of Our Current Healthcare System

November 15, 2022

Podcast host Joe Sparks imagines an adversary of the United States inflicting as many deaths as the U.S. health care system does on an annual basis.

“If this did happen, people would be outraged and demand action,” he says, adding that, “What I have described is real, and we are doing it to ourselves.”

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

https://medicareforallexplained.podbean.com

Capital, Surplus Classes, and Health Reform

Summary: A communist perspective on health pushes the boundaries of reform. For many progressives, it’s too much. But it’s a legitimate and valuable part of the discussion. Let’s meet in the Town Square to see how we can reconcile our perspectives, unite our caring, and agree on a solution.

Health Communism, Verso 2022, by Beatrice Adler-Bolton and Artie Vierkant

Excerpts:

Capital has been allowed to define the meanings, terms, and consequences of “health” for long enough. We articulate how health is wielded by capital to cleave apart populations, separating the deserving from the undeserving, the redeemable from the irredeemable, those who would consider themselves “workers” from the vast, spoiled “surplus’ classes. We assert that only through shattering these deeply ingrained binaries is the abolition of capitalism possible.

Some readers may be surprised to find little attention devoted in Health Communism to the question of health insurance. We understand health insurance companies for what they are: principally, they are financial institutions, concerned as they are only with payments for services rendered and the endless, bureaucratic, deadening, management of risk. There is no place for them in society.

It is important to recognize that, even as we fight in the US for policies like Medicare for All, the task at hand is much greater than one program could capture. It is the total reformation of the political economy of health, and in so doing, the total reformation of the political economy.

Capital has emphasized and corrupted the delineations between surplus classes for its convenience; it is immeasurably threatening to capital to see a group of those it has deemed to be waste come together in solidarity.

We are each of us ripped and maimed, strangled and buried by capital, in one way or another. That entire industries exist in plain sight to see us along this vast process of endlessly iterative life chances, to then subject us to extraction when we are surplus and no longer of use, and to eke out slivers of profit from our eventual deaths, is capital’s greatest sleight of hand. We are all surplus.

The host-body relationship of health and capital can be understood through an analysis of the social determinants of health and their direct relationship to the broader political economy. It is present in each of the accounts we have demonstrated throughout Health Communism; with each stage, with every evolution of the political economy of health, capital has come to occupy and replace more and more components of its host. But capital cannot kill its host body, or it would have nowhere to hide, nothing to exploit, a barren universe. It is for this reason that capital only fears health. It is up to us to separate them.

Comment:

By Don McCanne, M.D.

There is a great need to increase communication on the concepts that will bring health care justice to all. The title and rhetoric of Health Communism may not seem like it would fall in line with this goal, but it clearly does. Understanding the views of those who sincerely care about the health of all of us is important, and so it is important for us to make a sincere effort to understand those views no matter what ideological and rhetorical frames they adopt.

What about understanding the views of those who don’t seem to care? The capitalists. Rather than not caring, it is much more likely that they communicate amongst themselves, distracted by payment methods and the like, developing modes of behavior and rhetoric that merely suggests that they don’t care. Maybe we should be having more conversations with them, asking them questions that would bring out answers to show that they really do care.

Maybe it’s time to agree to meet again in the Town Square and bring all of our ideas together so that we can develop that system that will work for all of us. Of course, if we’re all there to ensure health care justice for all, it is likely we would end up with a universal social insurance system: single payer. We would also address the social roots of health inequity. And as we have suggested before in HJM, Medicare for All may not be enough: we may need to take on capital interests more broadly. That’s a tough but necessary conversation in the Town Square.

http://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.

Local Illinois vote suggests Medicare for All is popular

By Pamela Gronemeyer, M.D.
The St. Louis Post Dispatch, November 14, 2022

With all of the excitement about the recent midterm elections, two nonbinding resolutions in Edwardsville Township (Edwardsville and Glen Carbon) and Cunningham Township (Urbana) certainly fell under the radar. These were resolutions put on the ballot using Illinois’ grassroot township rule that allows activists to bring a petition to the annual April township meeting with signatures of at least 15 registered voters to introduce a referendum question for the November election.

The issue is voted on at the meeting by all registered voters of the township who are present at the meeting, A simple majority wins. In these two townships, activists were able to pose a question about whether the federal government should create a Medicare for All program to ensure equitable, quality and sustainable health care in this nation. The initiatives won by 64.3% in Edwardsville Township and 84.1% in Cunningham Township.

These two ballot initiatives bolster national polls showing the popularity of Medicare for All. Forty three percent of those insured under their employers’ health insurance are underinsured and are reluctant to seek care if they have to risk large copays and deductibles.

I believe it’s time for the U.S. to join the nations of the world in making health care a human right. The pandemic proved that all people need health care.

https://www.stltoday.com…

Midterms Debrief: Democracy’s Prospects & Single Payer

Summary: Tuesday’s midterm elections pitted Dem efforts to build social welfare and protect abortion rights and democracy against GOP blaming Biden for inflation and crime, and advocating for limits on abortion. The Dems performed strongly, but threats to democracy loom. We explore how the fights for democracy and single payer align.

Comment:

By Jim Kahn, M.D., M.P.H. and Kenneth ColĂłn

What the midterm election told us:

The nation averted the “red wave” endorsement of MAGA politics, with the best first midterm result for a Democratic president in decades. Voters responded to appeals to protect abortion rights and democracy, and largely didn’t blame Biden for post-COVID inflation. Yet it’s not time for complacency: American democracy remains in danger.

CNN reports that of the 34 Republican candidates for Secretary of State or Governor who rejected, questioned, or tried to overturn the results of the 2020 election, 11 are projected to win their races. The Republican National Committee has supported 70+ “election integrity” lawsuits, intending to suppress votes and systematically deprice Dems of full representation, as in the case of hyper-aggressive gerrymandering. A GOP Senate, if that happens, will obstruct Dem appointments to courts and agency oversight boards. The US House of Representatives will likely be GOP-controlled. This will likely lead to nearly nonstop hearings attacking Biden and other favorite targets of the Right to build support for a 2024 GOP presidential win. With a GOP president, traditional norms on stability of domestic and foreign policies will be jettisoned via bureaucratic subterfuge (a reclassification of civil servants as “policy making” thus depriving them of job protection, affording the president massive power to enforce loyalty over law). Meanwhile, the US Supreme Court will consider a case next month that may put control of federal elections solely in the hands of state legislatures — some of which, as a byproduct of extreme gerrymandering, deviate sharply from the views of their constituents. A Dem presidential candidate may win more votes, yet the state electors go to the GOP.

To be sure, there are encouraging signs in the mid-terms. Support was high among young Americans, who leaned very Democratic due to progressive values and favoring student debt relief – helping achieve impressive Dem overall and progressive results. We also elected our first Gen Z member of Congress. More and more, it appears that voters are recognizing and reacting to the threats to democracy. This offers hope of further broadening of resistance to GOP efforts to undermine majority rule.

Where does health reform fit in?

Small changes nudge us in a good direction, e.g. in the Inflation Reduction Act: more subsidies for the ACA, and Medicare drug price negotiations, constraints, and out-of-pocket spending limit. Yet single payer would do much better at controlling overall health care costs and save families thousands of dollars.

Beyond that, single payer is the health reform that most faithfully embodies the democratic values we’re fighting for. Equality would jump as universal, high-quality insurance replaces being uninsured, under-insured, or insured by under-funded programs for the poor. Liberty would rise by delinking work and insurance coverage, and offering real, unfettered choice of providers — not false choice among over-priced insurance plans. Small businesses and entrepreneurship could flourish as a result. Community would blossom by fostering the shared experience of access to care and elimination of medical debt. Americans could live longer, healthier, more fulfilling lives.

Is there a viable link between promoting single payer and saving democracy?

Single payer proposals engender massive attacks as “socialism” and “government takeover”. It isn’t, of course — it’s public financing of private care. Notably, even modest and inadequate reform ideas like a public option are similarly attacked, so we might as well think big, aiming for an approach that would really solve health care financing problems. Fortunately, people are increasingly recognizing the fundamental failings of our fractured insurance mess and thus the need for real reform.

So, how can we link the fight for single payer with the fight for democracy? Here are some ideas:

  1. Understand the links – where do the values overlap? We started above and are exploring other shared values. But we’d like to broaden the discussion and disseminate this idea.
  2. Explore alliances – convene organizations working on single payer and democracy preservation for structured discussion and mission coordination.
  3. Scrutinize the idea that the Dems should focus on small-bore incremental health reforms rather than single payer, which generates vigorous attacks from the GOP interests vested in our current health system. One potential counterargument is that only comprehensive health care financing reform broadly and powerfully advances democratic values. It’s the only way to control costs globally and for families. Another is that all healthcare reforms proposed by Dems will be condemned by the GOP anyway, so Dems should not let the GOP guide their healthcare strategy.
  4. Broaden political involvement. For people excited about these issues and energized by midterm results, and perhaps thinking about working with the local political party, or volunteering in elections – now is a great time to start.
  5. Encourage discussion. With friends, family, neighbors, anyone who will engage. Spread the word, but also listen well to their thoughts, beliefs, and concerns.

Let’s make meaningful progress on the parallel and aligned fronts of democracy and health care justice!

http://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.

Dunn County voters turn out to pass health care referendum

By Audrey Korte
La Crosse (Wisc.) Tribune, November 9, 2022

In July, the legislative committee of Dunn County approved a referendum question that is unprecedented in rural America. The question asked Congress and the U.S. president to nationalize health care.

Generally, attempts such as these come from large, urban areas. They might come with a left-leaning agenda. But the Dunn County Board of Supervisors voted unanimously to add this question to the November ballot despite the fact that many of them are conservative.

The referendum passed on Tuesday with 9,049 voting yes — 51% of county voters; 8,564 people, or 49%, voted against it.

“My first reaction when they came in at 51% to 49% was initially, a little bit disappointed that it wasn’t more (favorable) but when I started digging into the numbers more specifically, I understood how big of a win this actually is,” said Monica Berrier, a Dunn County supervisor.

“This was the most important issue on the ballot. When you look at the total number of votes that were cast in this race, the referendum issue had more votes cast, total, than any other race (in the county),” she said.

The referendum had about 34% more votes cast in Dunn County than the governor’s race and Senate race, Berrier said. That means that people showed up to vote on the health care issue alone.

John Calabrese, who’s spent months working to support the effort in the hopes that the referendum would pass, said he finds the numbers from yesterday’s race “fascinating.”

Voting for national health care fared better than voting for Democratic candidates, numbers show.

“When you consider that the referendum got 51.4% approval, and Governor Evers got 39% in Dunn County, and Mandela Barnes got 36% — it just says to me that this is not a partisan issue, which is the main point of why we were pushing it. Because we don’t think it’s a partisan issue,” Calabrese said.

The results were encouraging, Berrier said. They demonstrate that the issue of national health insurance is not a single-party issue.

“It wasn’t the case that the left-leaning city of Menomonie carried this. There was significant support in the rural areas as well,” Berrier said.

“When you compare the number of votes that we got for the referendum compared to the votes that we got for Tony Evers, the referendum had more yes votes than Evers by 12% points. So that suggests that there are quite a few conservatives who voted for (Tim) Michels who also voted for this referendum. That was really encouraging.”

Results of this referendum could make waves in Wisconsin. Other counties are considering putting the same question to voters in the spring.

“What I hope is that this discussion in Dunn County will inspire other counties to do the same. And I think that if other counties across Wisconsin, and even into other states start doing that, I think that the federal legislators are really going to have to start to pay attention,” Berrier said.

There also are people in Minnesota, California, Texas, Massachusetts and Kentucky that are paying close attention to this referendum. They hope to be able to replicate what’s happening in Dunn County in their states.

For now, Berrier and Calabrese want to make sure this referendum has meaning, that it can be replicated across the state.

“I think we need to continue to take it to other counties and try to replicate the formula and remember what works,” Calabrese said. “There’s a tendency among people who are involved to want to, you know, reach out to county board supervisors and other counties and I think that’s important, but a key part of why this was put on the ballot was the input from actual citizens of Dunn County, imploring their county board to put it on the ballot. So there needs to be a groundswell localized in each county.”

Passing the referendum won’t immediately affect national policy. However, it does tell the state and federal governments that residents of Dunn County want new national health care options.

“I think it’s really exciting that Dunn County is breaking ground here and being the first county in the state to do this,” said Berrier. “And I think it’s really important for us, and the local government, to give the people a voice on national issues as much as we can.”

https://lacrossetribune.com…

Secret rules, denials & fraud: The dark side of Medicare Advantage

By Brenda Gazzar
Code Wack Podcast, November 7, 2022

What are the major differences between Original Medicare and Medicare Advantage? How do the two programs compare when it comes to accessing care?

To get the facts, join host Brenda Gazzar and Ed Weisbart, M.D., a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.

From narrow provider networks to pre-authorizations and claims denials, Dr. Weisbart shares the nitty-gritty on Medicare Advantage. What is the Medicare Advantage business model? Why are so many Medicare Advantage insurers being accused of fraud?

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on America’s callous healthcare system, how it hurts us and what we can do about it. I’m your host, Brenda Gazzar. This time on Code WACK! What are some of the possible dangers and pitfalls of Medicare Advantage plans and how do they respond to patients’ needs differently compared to traditional Medicare? To find out, we spoke to Dr. Ed Weisbart, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program.

(5-second music stinger)

Welcome to Code WACK!, Dr. Weisbart.

Weisbart: Well, thank you Brenda.

Q: It’s open enrollment time for those signing up or renewing their insurance and a critical time for Medicare recipients who face a major choice between traditional Medicare and Medicare Advantage. One key difference between traditional Medicare and Medicare Advantage is who pays the claims. Can you talk about why this difference is so important?

Weisbart: Yeah, thanks. It’s a really important distinction. So when Medicare pays your claims as it does in original or traditional Medicare parts A and B, when they pay your claims, that’s their only job is to pay your claims. They don’t get in the way, they’re not not trying to make money off of you. You have Medicare as your health insurance. You go to the doctor or hospital that you want and Medicare pays your claims and it’s that simple almost.

But if you have opted into Medicare Advantage, Medicare itself is no longer paying your claims at all. Instead, Medicare is paying an insurance company to pay your claims and the insurance company as we all learned from having employer-based insurance and other things is really not out to just pay your claims. They’re out to make money off of this and so the more often they can avoid paying your claims or deny paying your claims or delay paying your claims or make it complicated for anybody to get a claim paid, the more they can do that, the more money they can make <laugh>. So they’re no longer really focused on you. They’re now focused on their own profits and that’s completely different than having the government just pay your claims and having Medicare pay your claims.

Q: Wow, and so how do the two programs differ when it comes to provider networks and access to specialists?

Weisbart: Same kind of difference. So provider networks in traditional or original Medicare, 89% of adult medicine physicians accept traditional Medicare as a payment model, 89% of adult medicine physicians and actually 96% of surgeons accept traditional Medicare and you can go to any of them that you want frankly with traditional Medicare. There isn’t a number like that for Medicare Advantage, but it’s significantly smaller. <Laugh> You know, there is no place where that data is collected for Medicare Advantage. So we don’t know what that is, but we know that their business model is to direct you towards the doctors and hospitals that they prefer. That may not seem important when you’re relatively younger and healthier. Certainly before your Medicare age or when you turn Medicare age, you may not really care. You think, ‘Oh well you know, I’ve had to change doctors before. My employer has done that to me, I’ve had to do that.

I don’t like it, but you know, I’m healthy, relatively.’ But as you get older, as your health becomes more vulnerable and you have more health issues, you become if anything more determined to want to see the doctor and hospital that you want and so Medicare Advantage, you may be willing to make that trade off when you first join Medicare and think, ‘Oh, they’ll tell me and I’ll deal with that.’ You need your health insurance when you are sick. The older you get having Medicare Advantage restrict which doctors you can go to or even change, You know, Medicare Advantage networks can change any time. You can have the Medicare Advantage program that you bought during open enrollment this year that you picked because it included your doctor and Medicare Advantage programs have the right to get rid of that doctor from your network at any time during the year.

So you’re out of control. You know, if you have Medicare Advantage, you no longer have the ability to pick which doctors and hospitals up to a point. You know, it usually only becomes an issue when you’re really sick near the end of life, when you need something complicated or you know, highly specialized, that’s when the money really matters and that’s when the Medicare Advantage networks really become intrusive and you may not run into that for a while. So, you know, and look outside of your state. What if you’re traveling somewhere else? What if you’re someone who spends a couple of months for the winter or the summer or somewhere else? Your insurance in Medicare advantage may not cover anything but the most dire of emergencies, if you’re not in your so-called service area. That may not matter when you’re younger and healthier, but the more medical conditions you acquire, the more important that becomes to you.

Q: Mm, wow. So do you know how the Medicare Advantage plans pick which doctors that they want to work with?

Weisbart: It’s a trade off between what they can contract them for and how important that is for selling their product. So sometimes a large hospital in a community may be able to command a high rate and from the insurance company and they’ll work it out cuz the insurance company feels that they have to have that hospital. But the trade off to that for the insurance company is if that hospital focuses on some very expensive condition, if it’s a cancer network for example, the Medicare Advantage plan may actually decide, ‘well yeah, we’re not going to get as many members to sign up for Medicare Advantage if we don’t include this high powered, you know, specialty cancer center. But those are primarily the really sick, expensive patients who we didn’t want to begin with.’ So sometimes the Medicare Advantage plans actually decide not to cover the top end hospital in your community or elsewhere in the country because they don’t want to attract the people that really want those top-end hospitals.

And we’ve seen this over and over again. I mean, there’s a ton of data that shows that 
 I was just reading this morning actually about nursing homes that people in Medicare Advantage in general are forced to use the lower quality nursing homes compared to people in traditional Medicare that have more flexibility and can go to the nursing homes or home health – that Medicare Advantage patients are more likely to be connected up with a lower quality home health agency than are people in traditional Medicare. But let me quickly say that that’s not everybody that’s just on the average. If you look across the board, there are still of course some splendid care, you know, and home health and hospitals being delivered within Medicare Advantage. I’m just saying, you know, playing your odds, your odds are worse for getting really the best if you’re in Medicare Advantage.

Q: Wow. I’m glad you pointed that out. I mean, my guess is not a lot of people know that about Medicare Advantage plans.

Weisbart: I know. There’s an awful lot of people don’t know about it and they just see Joe Namath on TV or some other, you know, ad which we can talk about on TV and Medicare Advantage offers lots of perks to convince you to join and you don’t realize what you’re trading off for a number of reasons.

Q: Right, right. What about pre-authorizations. In 2021, Kaiser Family Foundation found that 99% of Medicare Advantage enrollees are in plans that require prior authorizations. How does this affect doctors and patients?

Weisbart: Yeah, a prior authorization is as you know, before you can get something that your physician, you and your physician think is medically necessary and appropriate. Prior authorization means that for the insurer to pay for it, the doctor typically has to call the insurance company and get permission, get prior authorized to do the thing. That’s something that’s almost unheard of in original or traditional Medicare. It’s, you know, pretty much if you and your doctor want you to go get something in original traditional Medicare, that’s the end of the story. You go get it. You have to deal with the copays and deductibles for which there’s a strategy that we need to talk about, but there’s nobody asking you to get approval or prior authorization.

Whereas Medicare Advantage, it’s the exact opposite. There’s an awful lot of things that you just simply can’t go get, even if you and your doctor think it’s important and medically necessary and appropriate. There’s this, you know, set of bureaucrats in a Medicare Advantage company, an insurance company that knows if it’s expensive, that’s less profit for them and so they require the physician to get it prior authorized.

And even if the answer is yes at the end of that prior authorization, we as physicians, we buckle down and we do it most of the time, but we’re loathe to do it. It makes us, you know, really think twice because it’s expensive. I have to take time out of my day or I have to hire someone on my staff to take time out of their day to spend hours and hours jumping through these hoops and calling for approval and then the insurance company says, ‘Well, but we don’t really approve that much of it and so call back again and we’ve seen stories of people fighting the denial, getting an approval in a nursing home. I saw this once in a rehab center. They were denied extent more care. It was clearly appropriate.

And so the patient pursued getting an exception. They went through the exception process. The insurance company ultimately gave them the exception. Only three days later they were in the same situation. And the insurance company said, ‘well, we gave you those two or three days but not the next two or three days’ and there are people who go through that cycle, six, eight even. Well I heard a story of somebody who did it 10 times before she reached the end of her rehab course that her physician and physical therapists and the facility and indeed the patient and the family, all thought was valuable. So it’s really onerous. It makes us not always do the things that we think our patient would benefit from. The patient is really aggravated by that process cuz it’s aggravating just to talk about it right now. But often when you’re sick, you know, you have brain fog, you know, we talk about that with COVID and it’s true, that’s a whole thing, but in lots of illnesses it’s just overwhelming to be dealing with a life-threatening major chronic, you know illness and then on top of that, in that scenario, to have to deal with this third party, this insurance company, the Medicare Advantage folks who were only looking out for their bottom line and for their Wall Street traded profits, they make money the less care you get and that’s a fundamentally flawed problem as compared to, you know, (traditional) Medicare where it’s not like that.

Q: Right. It seems like patients might just give up too.

Weisbart: They do and that’s what the insurance company counts on and, and the insurance company counts on. So what are you gonna do, complain, What are you going to do? Switch to a different insurance company, Victory <laugh>, we’re happy if we didn’t want you here to begin with, you’re too sick. So, you know, your leverage over the insurance company, over theMedicare Advantage company is pretty limited. So yeah, patients do give up, doctors give up and you know, well, we’ll muddle along and it’s, you know, a lot of those things shouldn’t happen.

Q: Wow. Thank you Dr. Weisbart. Overall, how do Medicare Advantage plans respond to patients’ medical needs versus traditional Medicare with Medigap?

Weisbart: Yeah, so they get to decide, you know, the Medicare Advantage company gets to decide and there’s double digit numbers of percentages of cases where the Medicare Advantage company applies their own proprietary rules about what’s medically necessary and what’s not. You could really legitimately call them secret rules about what they think is medically appropriate or not. And they were just fined for this. There was just a huge discussion of this by the (U.S. Department of Health and Human Services’) Office of the Inspector General a few months ago saying that Medicare Advantage companies frequently deny things based on their own secret proprietary rules that are still within the guidelines of what traditional, original Medicare says should be covered and, you know, they’ll keep talking about that, but as long as nobody forces them to change that in a fundamental way, they get to decide and they often decide much more narrowly than is decided in traditional Medicare.

And this was an OIG report, this was the Office of Inspector General report on the broad population so I don’t think that particular report resulted in any fines. It resulted in a recommendation to Medicare that you guys should tighten up your language on that so that they can’t get away with this and Medicare responded saying, you know, you’re right, we should tighten up our language. Well that’s, you know, okay, great – necessary but not sufficient. You know, you need to do a lot more than that and basically it’s not going to change cuz the business model of the Medicare Advantage plan is to get in the way of health care and so I don’t care how many roadblocks you put for them to act egregiously, they’re going to continue to do it. We’ve looked at Medicare Advantage plans and found more than 10 of them that have been convicted of fraud or settled for fraud to Medicare.

And those are the large ones. More than half of people in Medicare are in one that’s done that. You know we just saw it again Centene here where I live in St. Louis, Centene just last week settled for I think more than a million dollars for one of their subsidiaries that was getting in the way of people having necessary pharmaceutical care. They’re all doing that cuz that’s the fundamental business model, get in the way of healthcare as much as they can until the penalties are so big that it’s no longer their business model and that’s, that’s just not going to happen. Noneof this happens in traditional original Medicare and people need to know, and they’re opting to go into the Medicare Advantage plan because of a number of reasons we can talk about. These are the kinds of hazards to which they’re exposing themselves that they may not be able to escape once they’ve locked into.

Q: Could a patient’s health status affect whether they would be better off with traditional Medicare or with Medicare Advantage? Is there any case where they might be better off with Medicare Advantage in your opinion?

Weisbart: No, the only reason to pick Medicare Advantage is that the upfront short term costs, if you’re healthy, can be lower – the upfront short term costs if you’re healthy in Medicare Advantage than they would be in traditional Medicare, particularly if you have to buy a supplement, which you should. So the upfront short term costs are lower. But once you get even a little bit sick, the personal financial advantage of being in Medicare Advantage disappears. And I am unaware of any evidence of better health outcomes or a subpopulation that Medicare Advantage does a splendid job at. So you also have to, I also need to point out that this is, again, looking at all Medicare Advantage plans and there are probably some that do better and some that do worse, and we don’t have any data about that. Medicare doesn’t release, you know, meaningful data about which Medicare Advantage plans do better and worse. Medicare releases a star rating, they supposedly rate the quality of Medicare Advantage plans and they give them 1, 2, 3, 4, 5 stars based on how well the Medicare Advantage plan meets certain quality metrics. But those are really limited and almost all the Medicare Advantage plans do pretty well on those because they play to, you know, they know what the metric is, they perform well on that specific narrow thing but on a broad population, there’s no reason to think broadly they do any better at all.

Thank you Dr. Ed Weisbart from Physicians for a National Health Program or PNHP.

Do you have a personal story you’d like to share about our ‘wack’ healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…