PNHP

Dr. Ed Weisbart on “MRCC Medicaid Minute”

Dr. Ed Weisbart on “MRCC Medicaid Minute”

PNHP national board member Dr. Ed Weisbart appeared on the Missouri Rural Crisis Center’s “Medicaid Minute: Medicare Edition” podcast on December 6, 2022. Dr. Weisbart warned seniors about the false promises of Medicare Advantage plans. He added that many of the insurers that are active in Medicare Advantage are lining up to administer Traditional Medicare benefits through the ACO REACH program.

“They make more money the less health care you get,” he said, referring to the financial incentives that are present in both Medicare Advantage and REACH. “That is a radical transformation of Traditional Medicare [and] it’s rolling forward unless we stop it.”

COVID Settling Provokes Harm from Insurance Gaps

Summary: As the COVID crisis subsides from pandemic to endemic, special funding to support its care is disappearing. This leaves many uninsured without access to COVID care, despite daily cases still exceeding 50,000. Once again, COVID exposes massive gaps in our health insurance.

For the Uninsured, Covid Care Has Entered a New Stage of Crisis, New York Times, December 6, 2022, by Noah Weiland and Sarah Kliff

When Mandy Alderman caught the coronavirus in June for a second time, she hoped her usual primary care physician could prescribe a monoclonal antibody treatment or Paxlovid, the antiviral pill that has been shown to reduce the severity of an infection. But without health insurance, she could not afford a visit.

Ms. Alderman, 44, a former medical assistant in Lawrenceville, Ga., found a doctor willing to prescribe a cocktail of other drugs, but not the proven Covid-19 medications she wanted. She took what she could get. She had to lean on her aunt for the $85 it cost to retrieve the drugs from a Publix grocery store pharmacy near her home.

“I felt like I was irrelevant,” Ms. Alderman said, recounting the ordeal. “I felt like I didn’t matter.”

Difficulty getting care for Covid-19 has become an increasingly common problem for poor, uninsured Americans. After paying about $25 billion to health care providers over the course of the pandemic to reimburse them for vaccinating, testing and treating people without insurance, the federal government is running low on funds for Covid care for the nearly 30 million Americans who are uninsured. …

Adding to the dilemma for the uninsured, the administration is planning to allow vaccines and treatments for Covid-19 to hit the commercial market by next summer — a move that could further hinder access for those without health coverage.

The result, public health experts say, is the end of the universal access that Americans have had to Covid care during the pandemic, a rare exception in the fragmented U.S. health care system. As federal funding dries up, people without insurance may be left footing the bill for tests and treatments, or they may be discouraged from seeking care altogether. …

The problem is especially acute in states that have yet to expand Medicaid under the Affordable Care Act. Those areas, where Republicans partly or entirely control state government, tend to have a larger share of residents without health insurance than the states that have adopted the expansion.

“Because of Covid, we’ve been able to temporarily create a bright spot for care,” said Kody H. Kinsley, the top health official in North Carolina, one of the states that has not expanded Medicaid. He added, “That island is slowly vanishing.”

Michele Johnson, the executive director of the Tennessee Justice Center, a legal aid group that helps poor residents in the state, which is one of those that has not adopted the expansion, warned that people without coverage were facing a new risk of Covid-induced medical debt.

“We’re back to the old ways,” Ms. Johnson said, adding, “People are going without vitally important services, and/or they’re going into debt for the rest of their lives.”

For much of the pandemic, the federal government covered the cost of vaccinating, testing and treating the uninsured through a fund run by the Department of Health and Human Services. But that program shut down in the spring because of a lack of funding, and in September, the government stopped providing free at-home tests through the Postal Service for the same reason.

Roughly 50,000 coronavirus cases — a figure that is almost certainly a significant undercount — are being reported in the United States each day, and people without insurance can face an array of costs. Bills for tests can be large and unpredictable; some people have faced charges of more than $3,000 for the routine nasal swab. For those who become seriously ill, a hospitalization can cost more than $1 million.

Comment:

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

As we’ve written before, the COVID pandemic has revealed the hazards of our grossly inadequate insurance system. Including hundreds of thousands of excess COVID deaths.

Epidemiologists now speak of COVID settling into an “endemic” state – more predictable and manageable. Indeed, President Biden declared the pandemic over. In a sense, this is fair: major accomplishments in vaccination and therapeutics – including the highly effective drug Paxlovid – have transformed an overwhelming public health crisis into merely a serious ongoing health issue.

With this much-appreciated pivot, federal funding for special COVID support is falling. Programs to subsidize COVID care for the uninsured and under-insured are sunsetting. (Not that these protections were ever perfect, as we’ve noted.)

As a consequence, individuals infected with COVID face serious financial barriers to care: untenable choices between medical risks and financial burdens. The NY Times article elegantly describes this heart-wrenching situation.

Why do we do this to ourselves?

Oh, yes, I remember. Because there are profits to be made in preserving the scarcity of insurance and care. Because maintaining the fiction that health care can work as a market commodity enriches those who exploit the convoluted structures and rules we establish to pursue this myth.

How many decades of increasing failures of our health insurance non-system are enough?

When are the moral precept “health care is a right” and the practical insight “universal insurance saves money” sufficient to motivate doing the right thing?

When?

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.

Is Medicare Advantage too good to be true?

By Brenda Gazzar
Code Wack Podcast, December 5, 2022

Medicare’s 2023 enrollment period is ending on December 7 and Code WACK! is on the case! What are the true risks of choosing Medicare Advantage instead of original Medicare with a Medigap supplement? Are you risking your pocketbook, or your health? 

Both, suggests expert 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.

“Don’t get tricked” by Medicare Advantage, he warns, because there’s a lot at stake. Why don’t our lawmakers protect us by leveling the playing field between the two Medicare programs? To find out, listen to the episode!

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! How are Medicare Advantage plans riskier than traditional Medicare and how are such plans affecting the shrinking Medicare trust fund? 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.

Welcome back to Code WACK! Dr. Weisbart.

Weisbart: Oh, thank you Brenda. Nice to hear from you.

Q: So we’re continuing our recent discussion about the dangers of Medicare Advantage plans. How are Medicare Advantage plans riskier than traditional Medicare, both in terms of health and financial risk?

Weisbart: I like the way you asked that together because they are related. If you are given financial barriers to care, which you are under Medicare Advantage, you’re not going to get the same health outcomes. So we know that this is true for everybody in Medicare Advantage. We know that Medicare Advantage patients are significantly more likely to have cost related problems accessing care than are people in traditional Medicare who have purchased a Medicare supplement.

Overall, 19% of Medicare Advantage beneficiaries say they’ve had cost-related problems accessing care, whereas only 12% of people in traditional Medicare with a supplement say that. And that’s even more striking when you get sick. So people in poor or fair health have even more dramatic cost-related problems accessing health. It goes from 39% in people with Medicare Advantage who are in fair or poor health saying that they have cost related problems accessing healthcare to still 27% in people in traditional Medicare with a supplement. So traditional Medicare is not perfect by any means today, but in terms of personal risk financially and in terms of your health outcomes, it’s way better than Medicare Advantage is.

Q: Mmmm. Okay. If these Medicare Advantage plans are so risky, why is the government allowing them to be sold and even seeming to promote them at times?

Weisbart: The government is not just seeming to promote them <laugh>. Just last week I was watching TV and an ad came on saying, ‘hey, you know it’s open enrollment season again and there’s all sorts of new plans out there with all sorts of new benefits that you should be sure and check this stuff out’ and they didn’t mention any specific Medicare Advantage plan, but traditional Medicare hasn’t changed, but Medicare Advantage has so they were clearly talking about Medicare Advantage and I looked at the bottom of the ad I was watching on TV and it was paid for by the U.S. government – by the Health and Human Services, by Medicare, Medicare itself through our tax dollars is purchasing ad time on primetime television gently directing people from traditional Medicare into Medicare Advantage. I’ve personally never seen that before, but I saw that last week so that was eye opening.

And if you look at the Medicare book, you know everybody who is in Medicare gets one of these three-eighth inch thick books for Medicare every year talking about, you know, your options. It’s pretty hard to read through and not feel nudged towards Medicare Advantage so they’re doing that. More strategically or more importantly, I guess, the federal government is literally overpaying Medicare Advantage plans compared to what they pay for the same exact people were they in traditional Medicare. So the federal government pays Medicare Advantage plans roughly now I think it’s averaging about 4% more per year per person than that same person would’ve cost were they in traditional, original Medicare and the Medicare Advantage plans use that to promote themselves so they use that to claim that they give you eyeglasses or dentistry or some other gym club memberships. So that’s another way… the federal government is promoting Medicare Advantage. I mean, who’s going to pick a Medicare Advantage plan because they wanted the gym club? Healthy people. You’re going to pick Medicare Advantage because of dentistry. Maybe. But the dental benefit is so limited that if you actually have a dental problem, dental insurance from Medicare Advantage isn’t worth very much and eyeglasses, they’re going to be the bottom end eyeglasses and may not really actually meet your visual needs. All of those things are designed to attract relatively healthy people, but the things that you need that are expensive, they’re not doing those very often.

Wow.

Weisbart: So why is the government encouraging that? Well, I think it comes back to the question of how troublesome democracy is these days. You know, they shouldn’t be doing that, but you know, our legislature uses the Medicare Advantage insurance company as one of their larger sources of funding for their campaigns so they’re loath to take it on.

Q: How are the government subsidies that benefit Medicare Advantage insurers plus their business practices affecting the Medicare Trust Fund?

Weisbart: It’s a terrible problem. Medicare Advantage plans are paid 4% more for the same person than traditional Medicare and so where does that money come from? You know, directly siphoning off the money from the Medicare Trust fund. So our unwillingness to address this is jeopardizing the Medicare program for all of us.

Q: Right, good point. It’s very puzzling that Medicare is a public health insurance program that by design requires people to get some kind of private health insurance to fill in gaps in coverage. Why isn’t there any public insurance coverage for these gaps? Or why doesn’t the government just eliminate them?

Weisbart: Yeah, the answer in one word, again is democracy, but you can, if you’re pretty low income and you’re on Medicare, a lot of those folks are also eligible to get Medicaid and so that’s called dual eligible. They’re eligible for both Medicare and Medicaid so depending on your state, you might be able to get public insurance to cover a lot of the problems that are in traditional Medicare. But when you retire, your employer might not be paying for a Medigap policy.

What we want Congress to do about this is to fix traditional Medicare. Given how inbred the Medicare advantage insurance companies are with Congress right now, it’s a pretty heavy lift asking them to, well I would, I would want to eliminate Medicare Advantage. It’s a pretty heavy lift for them to do that and I think there’s a lot of Americans who wouldn’t want today to see Medicare Advantage go away because they are getting a short-term better financial deal.

What should be done is just what you were talking about. Instead, they should fix traditional Medicare and that wouldn’t be that expensive, but they should eliminate the copays, they should eliminate the deductibles, they should expand the benefits in traditional Medicare to include eyeglasses and hearing aids and dentistry and all the other sort of bells and whistles that are good things to have… If Congress just made a level playing field so that people in traditional Medicare or in Medicare Advantage had the same copays, the same deductibles, the same benefit design and had no copays and no deductibles and had the right benefit design, Medicare Advantage couldn’t begin to compete with that cuz all you’re left with then are the barriers to care. So yeah.

Q: Is anyone working on that?

Weisbart: One place to start would be to introduce an out-of-pocket maximum into traditional Medicare. So traditional Medicare has copays and deductibles, which if you’re not sick you don’t run into very much, but if you are sick, there’s literally no limit to that and that’s the key piece of protection that Medigap policies protect you with so that shouldn’t be the case. You know, there should be, you know, an affordable out-of-pocket pocket maximum as they’ve just passed with Medicare Part D in the next couple years or so, there’s going to be an out-of-pocket maximum for Part D so that if you have Medicare Part D, the drug benefit, your total exposure will be I think $2,000 per year and before they passed that a couple months ago, there was no limit <laugh>. So it’s a big deal that they’ve made that limit in Medicare Part D.

Let’s do the same thing in traditional Medicare, put in an out of pocket maximum to it. There is such a thing in Medicare Advantage and it’s many thousands of dollars, but there is a limit we should introduce, you know, at least the as good a limit, if not even a better limit as a starting point in traditional Medicare. And then of course, my point would be there shouldn’t be anything out of pocket. We know that paying out of pocket for health care dissuades you from getting important bits of health care. We know that. So we should stop doing that. We want people to be healthy and live longer.

Q: Thank you, Dr. Weisbart, what is your organization, Physicians for a National Health Program doing about these worrisome Medicare Advantage plans?

Weisbart: We’re doing everything we can. So yeah, go to PNHP.org or you know, go to Physicians for a National Health Program. We’re 25,000 I think physicians and medical students and nurses and pharmacists and some nonclinical people as well all around the country. I think we have a presence in every state and we produce a ton of the research that healthcare advocates around the country rely upon. So if you go to our website, you’ll find a wealth of information and we’ve over the last few years been turning more into an advocacy group. We’re advocating for exposing these problems and fixing it in the ways we were just talking about. So we would very much like to see a single-payer national health insurance program come in essentially by taking the problems with Medicare that exist today. We had a lot of discussion about Medigap and Medicare Advantage and part C and D and E and F and G and R.

You shouldn’t have to do any of that. You should just – you’re born, you get your Medicare card, go to the doctor, what do you want? And it stays with you, you know, till the end of your life and it should cover virtually every doctor and hospital. No copays, no deductibles. So that’s the model of one payer, single payer improved Medicare for all. And that’s the core thrust of our group Physicians for National Health Program or PNHP.org.

That’s the thrust of our group is to really educate and advocate around getting that for the United States and we see Medicare Advantage as a huge threat to accomplishing that because it takes this precious public good that the nation has built (in)1965. The country decided we don’t want people to have trouble getting to see their doctor go to the hospital and we constructed this thing called Medicare and over the last 20 years we’ve been turning it more and more over to Wall Street and venture capital and the investment community and for-profit people who are stealing the bricks and mortar from our beautiful public machinery so what we would want to see is really the country moving to a single-payer national health insurance, improving Medicare and giving that to everybody.

Q: Right. What else do you want us to know about Medicare Advantage plans?

Weisbart: Don’t be tricked <laugh>. That’s probably the most important thing is that, you know, there’s these very attractive ads on TV and, you know, countless pieces of direct mail that we’re all getting, and they don’t even necessarily say they’re Medicare Advantage, you know, they’ll just say, ‘look, you can get these extra things with Medicare. Look at the extra benefits. All you have to do is sign up here’ and you may not even know that what you’re looking at is what we’ve been talking about. You may not even know that.

So when somebody wants to give you something for nothing, they’re probably tricking you. They’re probably tricking you <laugh> and that’s the case with this. So the first thing is to, if you, if you get one of those brochures in the mail, or if you see, you know, one of the ads on TV promoting Medicare Advantage, know that you’re giving up the most precious, wonderful insurance in the entire country. You don’t want to give up traditional Medicare. It’s the only insurance I know of where you can go to almost every doctor and hospital anywhere in the country and if you buy a supplement with virtually no copays and co-insurance and no financial risk, you can just think about your health. So the one thing I would want people to really know is don’t be tricked. Don’t be deceived by Medicare Advantage plans.

Thank you Dr. Ed Weisbart of Physicians for a National Health Program.

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…

Plenty of benefits of single-payer health care

By Winchell Dillenbeck
Times-Standard (Eureka, Calif.), December 2, 2022

My name is Winchell Dillenbeck and I am a member of Health Care for All and Physicians for a National Health Program, a nonprofit statewide organization. Our mission is dedicated to achieving universal health care through single-payer public financing. Our goal is for all California residents to have guaranteed, high-quality, comprehensive health care.

A single-payer financing system has succeeded in countries throughout the developed world. People in these countries have better health and enjoy a lifestyle free of anxiety and worry about how to pay for a health crisis. All of this is accomplished at a lower cost to the people and businesses. The cost of health care in America is twice that of Western developed nations.

Our dysfunctional health care system is damaging our economy, suffocating our business, discouraging physicians and negatively impacting on the nation’s health while remaining unaffordable for a large portion of our citizens.

The key features of a Single-Payer/Medicare for All system include:

  1. Universal coverage: Everyone, no matter their age and ethnicity, is covered for life, regardless of their employment status, income level, health condition, marital status, or immigration status.
  2. Single-payer: One public agency versus numerous insurance companies.
  3. Comprehensive care: All essential and necessary care is covered including outpatient visits, hospitalization, ER, surgery, dental, vision, hearing, prescription drugs, mental health, reproductive and home health services, substance abuse recovery, and long-term care.
  4. Choice of providers: Patients choose their doctors, health professionals, and hospitals. There are no restrictive networks.
  5. Affordability: Eliminates the profit-driven motive of insurance companies; eliminates the high cost of executives; ends the wasted spending due to administration costs that account for the first 30 cents on every dollar spent on insurance; eliminate deductibles and co-payments; and saves money by negotiating prices for services, drugs, and medical supplies. It eliminates the employer based health care system and it allows individuals to have health care coverage if they lose their job or want to change jobs. Individuals and businesses pay less for health care coverage.
  6. Seniors: Eliminates supplemental plans and out-of-pocket expenses and includes vision, dental, hearing aids, and long-term care services.

The local chapter is the backbone of the organization. We activate people at a grassroots level by helping them understand not only how single-payer will improve their lives, but also how they can help make it happen. Local chapters organize panel discussions, host single-payer movie nights, attend fairs, send speakers to groups, meet with local legislators, write letters to the editor as well as a variety of other activities.

For further information, contact Health Care for All / Physicians for a National Health Program at healthcareforallhumboldt@gmail.com.

Winchell Dillenbeck is a member of Health Care for All and Physicians for a National Health Program.

Online version: https://www.times-standard.com…

Print version: https://edition.pagesuite.com…

Voters to Politicians: We Demand Health Reform

Summary: An important story mostly overlooked in the 2022 midterms is strong voter support for health reforms in the face of politician inaction. Ballot measures that passed included regulating medical debt collection, expanding Medicaid, and demanding universal publicly administered health insurance.

Arizona’s debt collection reform–a small step towards health justice, BMJ, November 23, 2022, by Christopher Robertson, Steffie Woolhandler, and David Himmelstein

Americans are swimming in medical debt—or, more aptly, drowning in it. And, if the results of elections in Arizona on 8 November are any indication, they’re angry about it. Proposition 209, a ballot initiative on whether Arizona should place limits on debt collection for medical bills, garnered support from nearly three quarters of voters. That lopsided margin is particularly striking in a state whose government has long been controlled by Republicans and where the 2022 midterm election votes were almost evenly split between Republican and Democratic candidates.

The Arizona initiative continues the US trend of voters passing progressive health reform policies for an individual state that their Republican controlled legislatures had resisted. In the November election, for example, South Dakota became the latest jurisdiction to use a popular vote to expand Medicaid coverage for people on low incomes—following states such as Idaho, Missouri, Nebraska, and Utah. Like Arizona’s proposition 209, these votes suggest a mismatch between US politicians and many of their constituents. …

For Arizonans, proposition 209 does nothing to reduce the amount of medical debt they acquire, but it softens the consequences. The proposition’s most notable provision caps the interest rate on medical debts at 3% (or a percentage indexed to the yield on US Treasury bonds). Nonetheless, federal law allows national banks to export higher interest rates from the states where they are chartered. Consequently, if Arizonans put medical expenses on a credit card, or take on medical debt with another national lender, that debt will be unaffected by the 3% cap.

Proposition 209 includes several debt collection reforms, and these apply generally, not just to medical debt. … [it] protects a portion of debtors’ assets and incomes, making them “exempt” from debt collection. …

These sorts of exemptions from asset seizure and wage garnishment won’t resolve the medical debt and all its attendant problems. Even if uncollectible, the debt stays on a person’s record and thereby can continue to impinge on their health and access to credit for subsequent medical care or other needed expenses, such as housing or transportation. …

Proposition 209 does, however, make it somewhat less lucrative for healthcare providers to pursue patients for unpaid bills. …

Although proposition 209 is an important effort, these sorts of changes can’t substitute for the US implementing a simpler, more humane system of universal and robust health insurance coverage. One can imagine a world where consumer medical debt doesn’t exist—but Americans aren’t living in it.

Comment:

By David Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

In the dozen years since the passage of the Affordable Care Act (ACA), policy wonks have applauded the shift to so-called “value based” payment. But this shift has had dire consequences: giant provider systems taking over local hospitals and physician practices, health insurer profits skyrocketing (mostly garnered from taxpayer-funded programs), and private equity marauders capturing a growing share of health care resources. Meanwhile, the number of Americans unable to afford care has surpassed pre-ACA levels.

In response, politicians have done … virtually nothing. The best that can be said is that they stopped Medicaid programs from expelling enrollees during the height of the COVID-19 pandemic, and tinkered with ACA premiums and Medicare drug costs.

When American voters have been asked whether that’s enough, they’ve answered, resoundingly, “NO” — in Red states as well as Blue. This year, Massachusetts voters in 20 districts were asked “Shall the Representative from this District be instructed to vote for legislation to create a single payer system of universal health care that provides all Massachusetts residents with comprehensive health care coverage including the freedom to choose doctors and other health care professionals, facilities, and services, and eliminates the role of insurance companies in health care by creating an insurance trust fund that is publicly administered?” Voter support was overwhelming: In Republican-dominated areas (yes, there are some in Massachusetts) as few as 55% voted to endorse that statement; in Democratic-dominated ones, as many as 87% did. Other communities across the US passed similar measures.

Now, more than ever, Americans need and want fundamental health care reforms that will assure universal, first-dollar coverage, and drive the money grubbers from the temple of medicine.

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.

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…

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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: Déjà 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…