Summary: CMS just finalized the 2024 payment rule for Medicare Advantage, weakening the draft rule. There remain massive overpayments and widespread barriers to care. These fundamental problems are inevitable with reliance on private insurer intermediaries.

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Biden Just Took the First Step to Overhaul Medicare Advantage. Many More Must Be Taken, Common Dreams, April 7, 2023, by Diane Archer

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The corporations that run Medicare Advantage plans are engaged in widespread waste, fraud and abuse, resulting in tens of billions of dollars of overpayments to them every year. The advocates and government agencies overseeing Medicare Advantage have spent nearly two decades reporting on this fraud and waste and urging Congress to overhaul the program. Few in Congress or the administration were listening. Now, the Biden administration is finally taking action, but it’s only a first step.

The Biden administration has just finalized a rule that begins to rein in these overpayments, at last putting a spotlight on an issue that Congress and the public have long overlooked. The new rule is a small step towards reining in some of the overpayments to the Medicare Advantage plans and protecting the integrity of the Medicare Trust Fund, though it is not nearly enough.

The insurance industry’s fierce opposition and the multi-million dollar fear campaign the health insurance corporations launched against the proposed rule was their admission that Medicare Advantage plans can’t provide coverage at a reasonable cost. Medicare Advantage only works for the insurers if they are wildly overpaid and profiting exorbitantly. It was their admission that they cannot do what they were created to do and are legally obligated to do. They cannot deliver Medicare coverage anywhere near as cost-effectively as traditional Medicare, let alone at lower cost, as they had promised.

The fight over small improvements to the flawed Medicare Advantage payment system reveals how challenging it is to fix Medicare Advantage and free it of the bad actors who are engaged in massive — sometimes fraudulent — overbilling of Medicare. Medicare Advantage is in need of a substantial overhaul, as the advocates, along with the Medicare Payment Advisory Commission, the Government Accountability Office and the Office of the Inspector General, have all been saying for years. …

The Biden administration also recently finalized another rule, aimed at addressing widespread and persistent inappropriate delays and denials of care in Medicare Advantage. Among other things, the rule attempts to streamline the Medicare Advantage prior authorization process. It spotlights and begins to address the serious risks some Medicare Advantage plans pose to the health and well-being of their enrollees — our nation’s sisters and brothers, parents and grandparents.

Though it goes further than any past rule in its attempt to protect Americans from the bad actor Medicare Advantage plans, it does not provide the public with important information as to which plans are the bad actors. Nor will it lead to the government’s cancellation of contracts with the worst-performing Medicare Advantage plans. Therefore, it will not keep the bad actor Medicare Advantage plans from continuing to inappropriately delay and deny critical care.

[HJM bolding]

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Comment:

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

Lobbying elected representatives and public scare campaigns are high-yield investments for health insurers. Their profits these days derive mainly from serving as intermediaries for Medicare Advantage and other public insurance programs. They spend millions to safeguard billions in excess payments from CMS. The rate of return may exceed 100:1. The Biden administration is starting to address overpayment, but their effort is undercut by massive industry push-back.

The final rule spreads the modest and overdue proposed adjustments over three years. If you want a good technical summary, look at the fact sheet. The net result is a payment increase of 3.3% for 2024, as compared with 1% in the draft rule. How much is the difference? $10 billion. All into profits.

And that doesn’t begin to represent the scale of the overcharging documented by the Medical Payment Advisory Commission (MedPAC) and others. Up to $50 billion per year.

The insurers no doubt also hope that delay will further benefit them — a more sympathetic administration might abandon the out-year adjustments. They might also argue that other much-needed broader changes must wait until these three years of slow adjustment are done.

This is a rules-based approach. Very long and complicated rules attempt to rein in private sector entities which spend every working day scheming how to evade and game those rules, to shift more of the Medicare Trust Fund to shareholder profits.

Diane does an excellent job describing the sweep of problems plaguing Medicare Advantage. She rightly calls for a major overhaul.

What kind of major overhaul would really work? So complete we might not want to use the word “overhaul”. We need to abandon the financial intermediary structure, which guarantees bloated costs and aggressive limits on access to care, especially expensive care.

We need to jettison the insurers, and use a structure like traditional Medicare, with payments directly from the program to providers. For everyone. Single payer, Medicare for All.

http://healthjusticemonitor.org…

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Summary: New research finds that in 2021 the US had nearly 900,000 excess deaths compared with wealthy European countries. About half were due to COVID and half due to other factors, including health care financing and delivery.

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‘Excess’ Deaths Surging, but Why?, Medscape, March 29, 2023, by F. Perry Wilson

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What do we mean when we say “excess mortality”? The central connotation of the idea is that there are simply some deaths that should not have occurred. …

That’s what this article does, calculating excess deaths in the United States by standardizing our mortality rates to the five largest Western European countries: the UK, France, Germany, Italy, and Spain. …

[page 2]

[E]ven before the pandemic, the United States had an excess mortality problem. This is not entirely a surprise; we’ve known that so-called “deaths of despair,” those due to alcohol abuse, drug overdoses, and suicide, are at an all-time high and tend to affect a “prime of life” population that would otherwise not be expected to die. In fact, fully 50% of the excess deaths in the United States occur in those between the ages of 15 and 64.

Excess deaths are also a concerning percentage of total deaths. In 2017, 17% of total deaths in the United States could be considered “excess.” In 2021, that number had doubled to 35%. Nearly 900,000 individuals in the United States died in 2021 who perhaps didn’t need to.

The obvious culprit to blame here is COVID, but COVID-associated excess only explains about 50% of the excess we see in 2021.

I’m sure some will take issue with the use of European numbers when applied to Americans. After all, Europe has, by and large, a robust public health service, socialized medicine, and healthcare that does not run the risk of bankrupting its citizens. How can we compare our outcomes to a place like that?

How indeed.

Dr. F. Perry Wilson is an associate professor of medicine and director of Yale’s Clinical and Translational Research Accelerator.

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Comment:

By Don McCanne, M.D.

According to the data discussed here by Yale Professor Perry Wilson, in 2021 alone, not counting COVID deaths, about 400,000 people died who perhaps didn’t need to, deaths characterized as excess.

When compared with the five largest Western European countries, all of which have better outcomes, how indeed can we come to any other conclusion than that they have superior structural characteristics in their health systems? This includes robust public health services, socialized medicine, and healthcare financing systems that do not risk bankrupting their citizens.

Better care, for less money, that includes everyone. Sounds like something we could do – with expanded and improved, single payer, Medicare for All!

http://healthjusticemonitor.org…

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Summary: A striking vision for how to pay for health care in our country.

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An Immodest Proposal

(for Excellent Financing of Our Health Care System)

From: A humble health economist
To: The U.S. public

Dear kind family, friends, colleagues, neighbors, and fellow citizens:

The health and happiness of our population being of the utmost importance, I make bold to propose to you that we establish a system to pay for health care in the United States of America. The means to achieve this grand goal must include a health care financing system of a most refined and ingenious nature. I have contemplated how to accomplish this, and herewith share my conclusions, which I hope and trust you will find quite compelling.

First, we must commit great resources to this noble undertaking. I propose one in five dollars of all economic activity, though I would settle at the moment for just 17-18%. Our dear neighbors of the north country and friends in Europe are too stingy, dedicating only 8-12% to this august mission. We ought gladly proffer high recompense for our fine curative consultations, potions, and surgeries.

Second, let us rejoice in diversity. Every citizen shall have a different assortment of health benefits, for certainly these varied benefits shall align magnificently with future medical and financial needs, however unpredictably they shall manifest. Varied services allowed, disparate access to doctors, and a joyous plethora of cost-sharing arrangements, including impressively large deductibles and robust cost-sharing.

Third, let us elevate choice. Ours is a free country, so each citizen (and approved non-citizen resident) shall be permitted, nay obligated, to choose among insurance purveyors and health plans. Some say, “Pick your poison”, but I say, “Exercise your free market rights!” Alas, selection of physician may be ever so slightly restrained by the untrammeled and wondrous choice of a restricted provider network. Individuals will understand and accommodate if the most able medical practitioner for a worrisome affliction happens to labor external to the designated provider panel.

Fourth, let us further magnify the spectacular granularity of everyday tasks, because complexity is life. Let each insurance plan have different rules and procedures for securing payment for doctors and hospitals, so that the insurers may devote many fine US dollars to administration. Likewise, the providers shall dedicate one dollar in eight to billing paperwork. Long live and prosper the accounting room, and the myriad financial clicks of the electronic health record.

Fifth, admire the prospect of home foreclosures, a true blessing to ease the housing crisis, as medical bills further impoverish the poor. Manifold thanks for lack of insurance, and uncovered and out-of-network services; 40% in medical debt and 500,000 medical bankruptcies each annum is good fortune that we may all celebrate.

Sixth, savor the frustration and exhaustion of physicians straining for hours daily to digitally inscribe copious billing information, for the subsequent burnout thins their excess ranks.

Seventh, cheer delayed diagnosis and treatment as pandemics encroach, and too the chaotic data of fragmented billing systems which prevent us from worrying ourselves with nasty facts about disease spread.

Eighth, let us revel in the shorter life span offered by this financing system, for life is brutal (most especially when we cannot afford to consult a doctor to ease our pains). The sooner over the better.

Ninth, praise the myriad ways in which our system specially affects the lives of the impecunious and visibly different, with less and worse insurance, inferior quality of care and outcomes, and earlier release from life’s painful bonds.

Tenth, glory be to profits and spectacular CEO salaries, for these reflect the soul of the American experience. Insurers, drug companies, and hospital systems shall garner at least 10% of all revenue to enrich the worthy and kindly shareholders. CEOs of non-profit hospitals shall rightfully earn $10 million per annum in salary and other well-deserved recompense.

Finally, let us embrace un- and under-insurance, for they are the means that enable the flourishing of this fine and perfect system. Yes, spending more than any other nation, infinitely varied health care benefits, choice of health plan constrained to a narrow network, complexity in our daily lives, foreclosed homes, burned out doctors, pandemics ignored, brutish lives ended early, the downtrodden slighted, and, best of all, burgeoning profits for the few – all are thanks to the worthy sacrifices of the not really well-insured.

Respectfully submitted,

James G. Kahn, M.D. M.P.H.
(apologies to Jonathan Swift)

http://healthjusticemonitor.org…

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Summary: Following another mass school shooting, a prominent GOP former governor calls for ongoing protests in the street to force real change. It worked in the Civil Rights Movement, and it can again. Let’s demand gun safety … and, while we’re out there, health care justice via Medicare for All.

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Interview of former Gov. John Kasich (R, Ohio) after tragic school shooting in Nashville, MSNBC, March 28, 2023, Andrea Mitchell Reports

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If Americans don’t protest gun violence, politicians will continue to ‘look the other way’

Gov. Kasich: Until people go into the streets and protest, we’re not going to see changes. In my state, had I been able to get five thousand, ten thousand people on the lawns of the state house, politicians would have passed what we wanted. I couldn’t get them mobilized. I was reading this morning about the Montgomery bus boycott. You realize that took over one year for the Supreme Court ultimately to act to end discrimination on transportation. If you don’t have the people rising up, like they did with civil rights, like they did to end the Vietnam war, if you don’t have that, the politicians are going to keep passing the buck. They’re going to listen to one group of people, and, frankly, if in fact we can have the kind of massive outpourings that we have seen in this country consistent about saving our children at this point and so many other tragic accidents then you put the real pressure on the politicians to do things that we all know that we can do while still preserving the right of the second amendment. Things can be done that can provide a safer environment for all of us in this country and most particularly our children. Without the protest, Andrea, I think we’re going to keep doing… 19 incidents, 19 incidents in school shootings this year! This is sick! I heard the lady talking about all the people she visited, God bless her, she along with all of the other people who have experienced this tragedy personally has to figure out a way to mobilize all of us to stand up and say. “Enough!”

Now what I said about those women down in Montgomery, they just kept marching. They just kept doing everything they could, and that’s what it’s going to take here. If we don’t have people to begin to get into the streets and say, “Enough of this!”… the women who were so worried about all the children… the men who say this is my family… we all have to mobilize. Without it, the politicians are going to look the other way. And it’s not going to happen in a week or two. It has to be ongoing in order to get this changed. That’s my opinion on it because I sat there trying to get things done, and I was frustrated the whole time. I did what I could with executive orders, as the president has done, but there’s a limit to it. We have to get legislative action with common sense proposals that can really make a difference.

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Comment:

By Don McCanne, M.D.

Now that guns have replaced auto accidents as the number one cause of deaths in children, isn’t it about time we really did something about it? We haven’t acted, with Democrats blaming Republicans for inaction and Republicans blaming Democrats for attacking their second amendment rights. But here we have one of the more prominent Republicans in the nation saying , “Enough!”

Mr. Kasich makes it clear that we cannot expect a responsible response to these tragedies from the politicians, as our nation’s political history has demonstrated. But he has much more faith in us, the people. All we have to do is to go into the streets, in mass, and protest. We need to march, and keep on marching. The politicians who are looking the other way will no longer be able to do so if we stay in their faces.

Our children …
are being slaughtered by gun violence …
and the politicians have failed us
To the streets everyone!

But wait …

We are spending more on health care than any other nation, yet we tolerate more suffering in children and others through mediocrity in health care and through the profound prevalence of poverty. While we’re demonstrating against violence in our children, shouldn’t we be simultaneously protesting this form of violence as well, violence that is quantitatively much greater and often just as tragic.

Yes. To the streets. … “No More Guns” at the top of our placards, but “Health Care Justice for All” below that.

http://healthjusticemonitor.org…

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Summary: A proposed law in the California Senate would instruct state officials to engage with the federal government on approvals and coordination for a state single payer bill. This is an important complement to a single payer bill in the Assembly.

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New bill would pressure Newsom to speed up work on single-payer health care, San Francisco Chronicle, March 21, 2023, by Sophia Bollag

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Gov. Gavin Newsom would face new deadlines on his administration’s work to revamp the state’s health care system under a bill unveiled Tuesday in the state Legislature.

Newsom, a Democrat, has said for years that he supports creating a government-run health system in California, including while campaigning for governor, but since taking office has not endorsed specific legislation to do so.

Early last year, when Newsom was asked if he supported a bill to create a universal, government-run health care system in California, he dodged the question, saying he was waiting for a report from a state commission studying the issue. That report came out last April, and endorsed a vast overhaul of California’s health system.

Transitioning the state from a system where private health insurance companies control much of the market to one run by the state would be a huge undertaking, one that would require permission from the federal government in the form of a waiver. On his first day in office, Newsom announced that he was pursuing such a waiver. More than four years later, California still does not have one.

A bill Sen. Scott Wiener, D-San Francisco, announced Tuesday would impose deadlines on the administration and give the Legislature a role in the process of securing a waiver. It doesn’t explicitly call for a single-payer health care system, and instead uses the term “unified financing,” which is the language endorsed by the report from the state commission.

Advocates of “single payer” generally endorse a system that is government-run, and where the state is the sole entity paying for health care. A “unified financing” system could take that form, according to the report, but could also include a role for private insurance companies that fiercely oppose a single-payer system that would put them out of business. The report does, however, call for distinctions between private insurance and government plans to be dissolved.

Wiener’s bill, SB770, would require Newsom’s health secretary to brief the Legislature on the status of its work to secure a federal waiver every few months, and to produce a formal report on the administration’s progress and plans by June 2024. It would also give legislative leaders power to appoint people to a group advising the administration’s work.

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Comment:

By Michael Lighty

With the introduction last week of California Senate Bill 770, advocates for health justice opened a new path to achieve guaranteed healthcare for all based on single payer financing.

Rather than propose a comprehensive policy bill developed by a few single payer experts (an essential component of our work but an approach that has not succeeded politically after numerous attempts), SB 770 seeks to engage health justice supporters of all stripes to collaborate on a proposal to be presented to the California Legislature under a definite timeline.

SB 770 is part of the newly launched Healthy California for All Now campaign. Our goal is to guarantee equitable healthcare to all California residents that provides better care at less cost for families, through public financing.

The campaign builds on the positive momentum created by the Healthy California for All Commission, which concluded that single payer (what they call “unified financing”) could save at least 4,000 lives annually and $158 billion in 2031. The Commission gave official approval for a program which it summarized as:

• All Californians will be entitled to receive a standard package of health care services;
• This package could include Long Term Care Support and Services, which would relieve huge and growing burdens that are falling on millions of families;
• Entitlement will not vary by age, employment status, disability status, income, immigration status, or other characteristics; and
• Distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage will be eliminated within the system of unified financing.

Those findings are incorporated into SB 770 as the first step in a process which directs the Secretary of the California Health and Human Services (HHS) Agency to:

• Pursue waiver discussions with the federal Center for Medicare and Medicaid Services (CMS) to facilitate the creation of a unified healthcare financing system;
• Establish a Waiver Development Workgroup of diverse healthcare system stakeholders appointed by the Governor, Speaker of the Assembly, and President Pro Tempore of the Senate;
• Provide quarterly reports to the chairs of the Assembly and Senate Health Committees on the status and outcomes of waiver discussions with the federal government and on workgroup progress;
• Submit a complete set of recommendations regarding the elements to be included in a formal waiver application, as specified, by no later than June 1, 2024

Single payer advocates are building an outreach and public education campaign to bring into legislative discussions health justice advocates from varied contexts: labor, expanding coverage for undocumented residents, reforming Medi-Cal, and rate-setting for health systems. This marks a critical broadening of our advocacy base. It will foster decisions on unsettled key policy and financing issues from the Healthy California for All Commission that the Legislature will support.

SB 770 and CalCare (AB 1690), the comprehensive single payer bill sponsored by the California Nurses Association, are on complementary tracks. The first legislative goal would be passing the collaborative engagement and advisory process in SB 770, to be followed by consideration of a comprehensive single-payer program, including the proposals in CalCare, which is slated to be considered in 2024.

It’s vital that advocates support the process. We must repeatedly highlight the broad and deep political support for single payer, and contribute to the resolution of key political, legal, and technical issues to support state single payer. SB 770 provides an essential opportunity and a path to guaranteed healthcare.

We have an historic opportunity to achieve political success for single payer – let’s seize the moment!

Mr. Lighty is President, Healthy California Now.

http://healthjusticemonitor.org…

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