By Adam Gaffney, M.D., M.P.H.
The Nation, March 29, 2022

At the stroke of midnight last Tuesday, the US government stopped covering the cost of Covid-19 testing and treatment for the uninsured. Funding for the Covid-19 Uninsured Program, established at the outset of the pandemic, had run dry, and Congress had failed to replenish it. The uninsured can now be subject to ruinous medical bills after a Covid-19 hospitalization, a threat that will surely drive some to avoid seeking care; notably, one testing company has said it plans to charge uninsured patients $125 per Covid-19 test, a fine that will deter testing and hence disease control efforts. In two weeks, Covid-19 vaccine administration for the uninsured will also no longer be reimbursable, likely reducing timely access to vaccination. With yet another pandemic wave looming on the horizon, the evaporation of support for a disadvantaged population at elevated risk of Covid-19 could worsen the spread and impact of this virus.

Two years ago, as Covid-19 first swept my state, my primary focus as a critical care physician was clinical work. I was seeing waves of patients with severe Covid-19 pneumonia fill the ICU of the safety net Boston-area hospital where I still work today. But being a health care researcher as well, I worried about how our nation’s fragmented, inequitable health care system would cope with the pandemic. With some 30 million Americans uninsured, and even more underinsured, I feared that high deductibles and copays would deter patients with respiratory symptoms from SARS-CoV-2 testing and delay their care—inadvertently contributing to viral spread and severe outcomes from this new disease. Though that outcome was attenuated by unprecedented measures taken by governments and insurers, we’re now inching toward a worst-case scenario. While it’s true that it has always been arbitrary to institute universal health care for one illness, we ought to be pushing toward greater universality instead of retreating from it; American health care should become more like Covid-19 care rather than the reverse. Indeed, without change, the latter will be rationed by ability to pay at a moment when treatment breakthroughs have made the need for speedy access to medical care more urgent than ever.

In the spring of 2020, it seemed unlikely that the government would put into place so many provisions to finance pandemic care. An April poll found that about 1 in 10 Americans would avoid care because of costs even if they believed they had Covid. My earliest Covid-19-focused research study estimated that nationwide some 18 million Americans at increased risk of severe Covid-19 due to advanced age or medical conditions were uninsured or underinsured. Nonetheless, the federal government outperformed my cynical expectations and took important if inadequate actions to provide semi-universal coverage for this specific illness. The Families First Coronavirus Response Act, expanded by the CARES Act, required full coverage of Covid-19 testing by insurers, and provided funds (now depleted) for testing and treatment of uninsured Covid-19 patients. Thus far, some $18 billion has been paid out for Covid-related care for the uninsured, including an average of $360 per uninsured person for Covid-19 testing. The federal government would later also directly purchase—and freely distribute—Covid-19 vaccines, and it took a similar approach with monoclonal antibodies and the new oral antiviral pills.

Such measures have played an important role in making the Covid-19 medical response—particularly the vaccine rollout—more equitable than much else in American health care. To be sure, inequality remained: In another investigation, for example, colleagues and I demonstrated that in 2020 the uninsured were less likely to have a Covid-19 test than those with health coverage, yet faced a greater burden of infection. In a third study, we found that even accounting for differences in age, the uninsured were vaccinated more slowly than those with health insurance, although vaccines were free—perhaps because they lacked an established relationship with a health care provider who might help address their concerns, or feared costs given past experiences. Work by others produced further evidence that America’s inequitable health care system hampered our Covid-19 response: County-level primary care physician density is tied to vaccine rates, even with control for various factors such as political orientation. Still, there is little doubt that absent expanded government coverage and support for Covid-19 care, things would have been infinitely worse.

But today, the stakes of this issue are higher than ever. At the start of the pandemic, outpatient treatment options for Covid-19 were so limited that most of it was really just triage: determining, for instance, who could stay home, and who should be evaluated in an emergency room or hospitalized. And for those of us caring for Covid-19 patients in hospital wards or ICUs, treating Covid-19 initially meant the (complex) provision of respiratory support and management of complications as they arose: There were no specific Covid-19 drugs. But things have changed: We soon learned that the use of the steroid dexamethasone prevented deaths among those needing oxygen for Covid-19 pneumonia; it is plausible that delayed initiation of such an agent could worsen outcomes for some who stay home despite low oxygen levels. Other drugs that tamp down the immune system in severe Covid-19 have also been found to save lives. Other work found mixed evidence of benefit for the intravenous antiviral drug remdesivir, perhaps because the benefits only emerge when given early. But with out-of-pocket costs for Covid-19 hospitalizations averaging $4,000 for the privately insured, and with the uninsured losing all coverage for hospitalization, the sorts of financially driven delays in care we observe across the health care system (including in emergencies) could also keep patients from benefiting from prompt intervention for Covid-19.

Yet the issue is far more crucial when it comes to new antiviral therapeutics for Covid-19, which must be taken early when it is still a cold and not yet pneumonia resulting in hospitalization. Remdesivir, paxlovid, and monoclonal antibodies each, if given early enough, vastly reduce the risk of hospitalization for high-risk Covid-19 patients. And the benefits of booster vaccines in restoring waning protection for high-risk individuals are now beyond doubt. In other words, we have the technological means for an effective medical response to this virus. Yet, even as this knowledge has accumulated, efforts to build a robust infrastructure to deliver it are faltering. In addition to pulling out the rug from under the uninsured, deficient funding will undercut the broader medical response to Covid-19: The Biden administration has said funding inadequacies will limit further purchases of these antiviral agents and fourth doses of vaccines, for instance.

It is perhaps naive to think that a single disease would forever remain carved out of the profit-oriented logic of American health care, although these recent changes are even more abrupt than I would have predicted. Even if a compromise is reached and funding replenished in coming days, it will only be a (much needed) Band-Aid—a temporary and inadequate fix for a virus that is not going away, to a health care system whose deficiencies will continue to undercut our pandemic response without deeper reform. Make no mistake: Congress must take action to restore coverage for Covid-19 care for the uninsured, and to fund the broader pandemic medical response, today. But a universal medical response, achievable through realization of a comprehensive national health program, will be needed to combat Covid-19 for many years to come.

Dr. Adam Gaffney is a critical care physician, an assistant professor at Harvard Medical School, and immediate past president of Physicians for a National Health Program.

https://www.thenation.com…

By Brenda Gazzar
Code Wack Podcast, March 28, 2022

What does it mean to “privatize” Medicare? What’s ACO-Reach? Why does it matter? Who’s for it, who’s against it, and why? Join host Brenda Gazzar and Ed Weisbart, MD, a retired family physician, former chief medical officer of Express Scripts and a national board member of Physicians for a National Health Program to get the low-down. Dr. Weisbart shines a revealing light on an issue that will impact the healthcare experience of almost every American aged 65 or older – the ongoing effort to give away Medicare to private, for-profit investors.  Should health care be “just another way” for investors and shareholders to make money? Is a for-profit Fire Department just around the corner?

---

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 our 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’s the latest with Direct Contracting Entities and the assault on traditional Medicare by Wall Street and the insurance industry? Who makes up the growing resistance to this program of the Center for Medicare and Medicaid Services and what are they doing to stop it? We recently 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, to get an update on some troubling developments.

(5-second music stinger)

Welcome to Code WACK! Dr. Weisbart.

Weisbart: Thank you, Brenda. How nice to see you.

Q: Thanks for joining us for an update on the latest moves to change Medicare. Last time we spoke was in October, 2021. At that time you explained what Direct Contracting Entities are, the danger they pose to traditional Medicare and the campaign Physicians for a National Health Program is leading to stop them. Could you give us a brief overview of DCEs? What are they and how do they work compared to traditional Medicare?

Weisbart: Well, thanks. I appreciate your talking about this. It’s a huge topic – really important. In 2020, the Trump administration launched a new experiment to privatize traditional Medicare, turning everybody who is in traditional Medicare today over to a new entity that is invested in by Wall Street – run by the for-profit (healthcare) industry and is most able to make money by reducing how much care, how much people get. So they’re currently live.

Medicare is currently going through their claims history on everybody in traditional Medicare and they’re determining who they think your primary care physician has been and if your primary care physician has joined one of these new organizations, Medicare assigns you without asking you to one of these new organizations that are a lot like the Medicare Advantage plans that people in traditional Medicare chose not to be in. You still have traditional Medicare, but they’re moving you into this new organization that’s the first time ever for traditional Medicare to have a for-profit Wall Street investment community designed to make money off of you rather than letting Medicare just provide health care to you.

Q: Uh-huh. And how is this like the Medicare Advantage plan?

Weisbart: It’s like the Medicare Advantage plan in that Medicare no longer pays your doctors and hospitals directly for you, but instead they’re paying this other organization for your health care and this other organization’s primary interest is making a return on investment to Wall Street, much like Medicare Advantage plans are primarily trying to, you know, serve their poor for-profit needs. You have a new financial middleman stuck in the middle of your health care. I heard somebody say a couple days ago. ‘Well gee, now I’ve got a doctor in my health care. I’ve got a nurse involved in my healthcare, but what I’ve really needed is a banker involved in my health care.’ So hooray this new program introduces a banker into your health care. That’s really dangerous.

Q: Wow, so are people already enrolled in this program?

Weisbart: Yes, we don’t know how many. Medicare’s not telling us that. We’ve heard at least 300,000 and maybe many millions of people in traditional Medicare without being asked and barely being notified are already being plucked out of their simple relationship and assigned to one of these new organizations. They’re all over the country. Medicare has announced that they plan to have 100% of people pulled out of traditional Medicare and pushed into one of these new programs by the year 2030. Technically, they’re still in traditional Medicare and can still go to any doctor that accepts traditional Medicare, but realistically, there’s now a for-profit entity that’s now focused on making profits rather than maximizing your health. I don’t want that involved in my health care.

Q: Hmm. Have we heard any first hand stories yet?

Weisbart: Not yet. It’s too new. We have lots of stories like that about Medicare Advantage, where we know that the sicker you are, the more likely you are to be unhappy and the more likely you are to want to get out. Medicare Advantage works just great if you’re not sick but that’s not when you … actually need health care. This program is too new for us to have much experience with it. But that’s why it’s so important for programs like Code WACK! to cover this because it’s not that big yet. It’s not too big to fail. It’s not too big for us to say, ‘Hey, here’s the alarm bell.’ Congress turn this program off. Stop this program.

Q: Okay. Question, is the new entity called ACO Reach or A-C-O Reach?

Weisbart: Technically, the name is the ACO Reach Model, but we just call it Reach.

Q: Is it the same thing now as a Direct Contracting Entity or what is A-C-O Reach?

Weisbart: Yeah, it is essentially the same thing only in some ways worse. It’s the same in that it’s got middlemen in the exact same way I was describing and these middlemen can keep potentially as much as 40% of what Medicare pays them. You know, traditional Medicare spends 98% out of 100% of the money they get, they spend 98% of that on health care and not on overhead or profit. The insurance industry spends more like 85% and keeps 15% for overhead and  profit. Whereas these new organizations – DCEs and now the Reach entities – are allowed to spend as little as 60% on health care and keep 40% for overhead and profits. Most will probably be in the 20-25% range, but still way worse. So  anyway, that’s the same, auto enrollment where Medicare assigns you is the same. The lack of limits on the size of these is the same. The incredibly wrong direction of this is the same.

But what happened was the Direct Contracting program got exposed and the country started to rile up against it and, and Medicare recognized, ‘oh my gosh, people know what Direct Contracting is. This DCE acronym is getting  radioactive. We have to change something.’ And so they did. A few weeks ago, they issued a new program that’s called, as you said, A-C-O Reach and we did a line-by-line comparison of what they’ve promoted so far about this new program versus the old DCE program and it’s the same with a couple of key exceptions. The new organizations are able to  actually make more money than the old ones were probably going to make and the new ones bear less financial risk if they don’t do a good job than the old ones. So it’s worse in that sense. You know it’s more profitable for these folks that are just raiding the Medicare trust fund.

And they can do that without taking as much risk. Now they did put in a lot of lip service to improving health equity because that was one of our charges was ‘your program doesn’t do enough for health equity.’ So the new program has a lot of lip service for improving health equity, which egad is an important problem, but it is at best lip service, the things that they’re doing about health equity. I’m not kidding you. They’ve distributed to these new organizations, a fill-in-the-blank, design-your-own health equity plan. It looks like something you’d give a fifth grader, fill in the blank and design your own health equity program when you want to be one of these new programs. Aside from how incredibly simplistic it is, there’s other problems. Number one, they get paid more for having that program. Number two, they’re not obliged to actually improve health equity.

And number three, this to me is Medicare overtly throwing their hands up into the air and saying, ‘we have no idea how to fix health equity.’ So all y’all come out and give us your own fifth grader plan to improve health equity. So No. 1, it  means no plan from Medicare, but No. 2, it means there’s going to be more than a hundred different plans to improve health equity. None of which could possibly be scaled large enough to actually have meaningful results…It’s just terrible.

Q: Yeah. My colleague Georgia calls it equity washing.

Weisbart: That’s exactly right. It’s equity washing.

Q: Got it. So just to confirm. Are DCEs still a thing now or are there only these Reach entities?

Weisbart: The Direct Contracting model continues until Dec. 31st of 2022 and then it ends and the A-C-O Reach model starts Jan.1st, of 2023 and some of them are able to actually start in August of 2022, but as of Jan. 1st, 2023, there won’t be any Direct Contracting Entities and they will all probably become these new Reach programs. So Medicare has announced that the current Direct Contracting Entities don’t have to reapply to become a Reach (entity) as long as they say, ‘we’re in compliance with what the DCE rules were,’ as long as they testify, they’re in compliance and they fill out a fill-in-the-blank equity program and a few minor things like that. They don’t have to even reapply so virtually all of the 99 Direct Contracting Entities today will become Reach A-C-O’s in 2023 and then we don’t know how many more. There is iterally, there’s no limit on how many more there will be approved for in 2023.

Q: Got it. Recently Recycle Intelligence reported that more than 200 organizations have come out against A-C-O Reach calling for the program to be terminated completely. And full disclosure, our parent organization, California OneCare (Education Fund) has joined the opposition out of concern that the program will eventually lead to patients losing their freedom to choose their providers. What other organizations are opposing it and why?

Weisbart: It’s actually north of 250. So hooray, you know, that it’s resonating. The organizations are all over the country and they’re of all different sizes. So it’s some of the more widely recognized organizations like Public Citizen and Social Security Works and Just Care and Physicians for a National Health Program that I’m part of. So, you know, fairly good size, large national organizations and then medium size and small ones. So chapters of the older Women’s League, some faith-based groups, Missouri Consumers Council, you know… The reason that’s important is that this demonstrates that there’s No. 1, it’s geographic. It’s not just, you know, a handful of people. It’s the whole country that’s speaking out against this and No. 2, it’s deep in the country. It’s broad and it’s deep. So all sorts of different organizations are joining this resistance movement. So, you know, when that happens, you usually win, but my gosh, we got to win quickly so that this doesn’t hurt people along the way.

Q: Yeah. And what are some of the main reasons that you’re hearing that there’s such concern about this?

Weisbart: People don’t trust the investment community as having any real interest in improving their health and they have viewed traditional Medicare as sacred almost, you know, sacrosanct as this is the one last little vestige we have of a really well-performing healthcare system and ‘I had to wait until I turned 65 to get into it and I paid into it for many years and now I’ve got it. And you’re going to think of messing with my Medicare? Not so fast, buddy.’

So they’re afraid that having venture capital and private equity and the insurance industry involved is going to disrupt the care that they so desperately want to hold on to. They’re concerned that there’s going to be people misguiding their healthcare decisions. You know, they’re concerned that this now suddenly puts their trusted primary care physician into a somewhat conflicted role, right? Because the primary care physician is going to now be under some pressure from these new organizations to direct their referrals inside of the Reachs’ preferred network.

Something happens to all of us and when that something happens to you, probably the first place you’re going to go for guidance on, what do I do now is you’ll go to your primary care doc and say, ‘Hey, you know, I saw on the internet, this looks like the best place to go. What do you think?’ You’ll probably still get really good advice from your doctor because most doctors want to give you the absolute best care that they can. But suddenly if you’re in traditional Medicare, you don’t know because now your doctor’s going to be under financial pressure for the first time ever for the first time ever in traditional Medicare, your doctor’s going to be under financial pressure to work within the reaches – what Reach wants to happen to you. And we don’t have experience with this yet, but we know every other time that’s happened from dialysis center to nursing homes, to hospitals to take your pick any other time that this has happened, it gets worse for patients and more profitable for industry and that’s exactly the wrong direction.

Q: Thank you Dr. Weisbart. What’s the status of the project now and what is the best case scenario and the worst case scenario from your perspective?

Weisbart: So at the moment the status is it’s live and it’s getting bigger. There are 99 of these entities today. We don’t know how many of these Reaches there’s going to be in 2023, but unless we succeed more – maybe hundreds, we have no idea – they will get more patients assigned to them. That’s all afoot. But we have growing resistance and growing reason to hope that the resistance will be increasingly successful.

In the last few weeks, we saw 54 members of Congress for the first time raise their voice and say, ‘this is unacceptable.’ Medicare, you have to stop this immediately. That’s a result of all the grassroots organizing we’ve been doing.

Q: Mmm wow. So what can we the people do about this?

Weisbart: First is learn more. There’s a lot of good high-level and in-depth information, if you go to our organization, Physicians for a National Health program or pnhp.org. And you’ll find a ton of both high level summaries and deep analysis. The second thing is when you go there, sign the petition. You know, we have a petition for individuals to sign. We’ve had, I think more than 13,000 individuals signing saying that they think that this should be stopped. Ask any organization you’re part of to sign the organizational petition, which is also on the website.

So If you’re in a church group, if you’re in a union, if you’re in any, you know, large or small organization, we’d love to have your organization. Then the third thing is call your member of Congress and just tell them, ‘Hey, I want you to know I’ve learned about the Reach program. I’ve heard about your trying to privatize Medicare. I’ve heard about these DCEs and I want you to stop it. I want you to become a Medicare protector, not a Medicare assaulter… and I’ll know if you do that and I’ll vote against you if you do that.

Q: Wonderful. Thank you so much. Is there anything else you want us to know?

Weisbart: This is a winnable short-term fight. If we don’t win it by the year 2030, everybody who has Medicare today will have a banker in their exam room. Anybody who has Medicare today will have a doctor if they have one, a nurse, if they have one and the investment community deeply involved in making a profit off of you not getting health care, everyone in traditional Medicare.

Thank you, Dr. Ed Weisbart.

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…

By Lee Russ
The Progressive, March 28, 2022

For some time now, the agency tasked with overseeing Medicare has been rather quietly killing the program. So quietly that you probably didn’t even know about it.

Many people consider Medicare to be politically untouchable, and that any attempt to kill it would end the career of anyone who tried. But there are many ways to gut Medicare. The sneakiest is to simply change the program into something else and still call it “Medicare.”

Liz Fowler, deputy administrator and director of the Centers for Medicare & Medicaid Services (CMS) Innovation Center, recently expressed support for an idea advanced by the Trump Administration to promote the privatization of Medicare, telling a group of doctors that the nation needs to get away from the “financial incentives in the U.S. health care system.”

Medicare is designed to give senior citizens direct access to medical care. That means no middlemen deciding whether you can see a doctor, which doctor you can see, or which service the doctor can provide (as long as it’s within Medicare’s broad coverage). That’s why Medicare has remained so popular and successful, and why it operates with far lower administrative costs than commercial insurance.

Fowler and others claim that this public model, which compensates doctors through a “fee-for-service” model, is so expensive because doctors often perform unnecessary services  to receive a greater payout. In its place, Fowler and CMS want a system where Medicare pays a lump sum per patient to an intermediary or gatekeeper. If the gatekeeper spends less than that amount, it gets to keep some or all of the “savings.” This system, known as direct contracting, gives doctors a financial incentive to limit the care that patients receive.

In essence, Fowler is advocating that we must give for-profit companies a financial incentive to restrict care, as a way of getting rid of financial incentives to perform unnecessary procedures. While there is some evidence that unnecessary services do occur, there’s scant evidence to support the belief that this is due to any widespread malintentions by doctors, nor that fee-for-service is a major culprit in the high cost of U.S. health care. But there’s considerable evidence that the alternatives are far worse.

In fact, replacing an incentive to provide care with an incentive to reduce care would mean the death of Medicare. Once you put a for-profit gatekeeper between the patient and the doctor, that’s no longer Medicare—that’s a version of commercial insurance.

Direct contracting is simply the latest in a string of CMS “innovations,” which impose gatekeepers to supposedly reduce costs. None of these innovations have actually lowered costs. Any for-profit gatekeeper will require some compensation for its gatekeeping, and the process of getting medical care becomes more complicated, increasing the amount of time and effort spent by both doctors and patients in communicating and negotiating with the gatekeeper.

Take the example of Medicare Advantage (MA). The commercial insurers that offer MA plans advertise heavily and participate only to make a profit. So how could these companies spend all that money on advertising, take out a profit, and somehow spend less per patient than traditional Medicare does? They can’t, of course. The evidence is that Medicare actually pays more per MA patient than it does per traditional Medicare patient. On top of which, there’s also evidence that MA insurers save money by restricting care.

Direct contracting is actually far worse than MA for two reasons: the gatekeepers get to keep a larger share of the supposed savings that they generate than they could under MA, and Medicare recipients are placed into the direct contracting program without their consent, unlike the MA program.

However, not even killing both the direct contracting and Medicare Advantage programs would save Medicare as long as CMS is committed to using gatekeepers to create the incentive to deny care. CMS would simply come up with another “innovation” to keep key care decisions in the hands of commercial intermediaries.

In fact, CMS just announced that it was killing part of the direct contracting program and renaming the rest to “Realizing Equity, Access and Community Health” (REACH), a new kind of middleman.

As long as decisions on care are in the hands of people who profit by denying care, Medicare will be dead—killed under the erroneous assumption that an incentive to provide care is the problem, and an incentive to deny care is the solution.

Can a program that affects so many Americans really die such a quiet death?

https://progressive.org…

By Matthew Cunningham-Cook
The Lever, March 24, 2022

A new Medicare privatization scheme developed under President Donald Trump and now being expanded under President Joe Biden is forcing hundreds of thousands of seniors onto new private Medicare plans without their consent.

The development represents a troubling new dimension in the fight by corporate interests to privatize Medicare, the federal health insurance program for people 65 or older. Medicare Advantage, which allows for-profit health insurers to offer privatized benefits through Medicare, already results in unexpected costs for routine procedures and wrongful denials of care. Private plans have cost Medicare an astonishing $143 billion since 2008, and are now driving some health insurers’ record profits.

The new Direct Contracting Entity (DCE) program similarly adds a private-sector third party between patients and Medicare services. Medicare allows these intermediary companies to offer unique benefits, like gym membership coverage. But as for-profit operations ranging from private insurers to publicly traded companies to private equity firms, these intermediaries are incentivized to limit the care that patients receive, especially when they are very sick.

While Medicare Advantage patients choose to sign up for private insurance plans, patients are being enrolled in these DCE health care plans without their informed consent. As Rep. Pramila Jayapal (D-Wash.) noted in a January op-ed, “Seniors in traditional Medicare may be ‘auto-aligned’ to a DCE if any primary care physician they’ve visited in the past two years is affiliated with that DCE. That means Medicare automatically searches two years of seniors’ claims history without their full consent to find any visits with a participating DCE provider as the basis for enrollment.”

Among those who unexpectedly found themselves caught up in one of these new DCE plans is Suzanne Gordon, a policy analyst based in Richmond, California. Gordon spent her entire professional career studying the U.S. health care system and advocating for Medicare for All. As a firm opponent of privatization in Medicare, she has never signed up for a for-profit Medicare Advantage plan.

That’s why she was so surprised when she got an email in January from her doctor at One Medical, a for-profit primary care practice on the West Coast backed by the private equity giant Carlyle Group. While the email message wasn’t particularly clear, she eventually realized that she was being enrolled without her informed consent in a new private DCE plan run by Iora Health, a primary care provider One Medical purchased last year.

“I got the email, I clicked on it and began a signing process that didn’t tell me what I was signing,” said Gordon. “You sign, you click in, and they tell you that they want you to sign up for a DCE with Iora Health. I wrote back to my doc and said I won’t do this… I felt that a line had been crossed.”

Gordon, a health policy expert, was able to get out of the plan — but others have not been so lucky. Rep. Pramila Jayapal’s (D-Wash.) office told The Lever that 350,000 seniors were in DCE plans as of January 2022 — none of whom elected to sign up voluntarily.

This latest Medicare privatization scheme was started under the leadership of a Trump official who has since launched his own “entrepreneurial firm focused on building and growing transformational health care companies,” with support from private equity firms. Now, the effort is quietly being expanded by the Biden administration through its new ACO REACH program, under the direction of two former Obama administration officials who have revolved between jobs in government and the corporate health care industry.

The development means that even more of the country’s most vulnerable will be at the mercy of corporate arbiters that they know little or nothing about.

“Seniors and people with disabilities are, without their consent or full knowledge, being put into a program that has as its center the profit of the investment community rather than the health of Medicare members,” said Ed Weisbart, a physician who chairs the Missouri chapter of Physicians for a National Health Program (PNHP), a doctors organization that advocates for single-payer health care. “The investment community has proven that they know how to work around the guardrails of any program that has been set up. They know how to do it.”

Privatizing Medicare

The DCE program was originally launched in April 2019 by Trump’s Centers for Medicare and Medicaid Services (CMS), under the auspices of the CMS Innovation Center, known as CMMI.

CMMI was created under President Barack Obama’s signature health care law, the Affordable Care Act (ACA), to pilot new payment models in Medicare and Medicaid without going through the formal rulemaking process that requires public comment. As a result, the new DCE program, which assigns seniors to a privatized model without their consent, has never been subject to any public scrutiny whatsoever.

“All that DCEs do is privatize traditional Medicare,” said Diane Archer, the CEO of Just Care USA, which works to fight Medicare privatization.

Meanwhile, Adam Boehler, who Trump tapped to run CMS’ Innovation Center, has since formed his own firm, Rubicon Founders. The firm’s website claims it will “architect transformational companies and are deliberate in creating the foundation necessary to lead an industry,” but provides few details on how it will do so. Rubicon did not respond to a request for comment.

Boehler’s firm launched with the backing of longtime private equity executive Annie Lamont, who is married to Connecticut Gov. Ned Lamont (D), as well as support from the health care-focused private equity firm Welsh, Carson, Anderson & Stowe (WCAS). WCAS is developing a series of primary care centers for Medicare Advantage patients with the help of Humana, a private health insurer that has also launched a DCE program.

For Archer, the evidence is clear: “Adam Boehler… launched this [DCE] program to enrich his friends in the private equity world.”

“We Needed To Make Sure That CMS Continues This Journey”

Late last month, critics of DCEs say the Biden administration effectively expanded the DCE effort under a new name — the “ACO REACH” program.

The new program — which stands for Accountable Care Organization (ACO) Realizing Equity, Access, and Community Health (REACH) Model — allows hospital-led managed care organizations to access the new Medicare privatization scheme, too. ACO REACH similarly assigns patients with little informed consent to for-profit plans that benefit health care profiteers and creates incentives to deny care.

The DCE and ACO REACH programs are being spearheaded in part by CMMI head Liz Fowler, a former Obama administration official who helped write Obama’s signature health care act as the chief health counsel to former U.S. Senate Finance Committee Chairman Max Baucus (D-Mont.). Earlier, she helped write the 2003 Medicare Prescription Drug, Improvement, and Modernization Act, legislation that barred the government from negotiating lower prescription drug prices.

Fowler served as vice president of public policy for the health insurer Wellpoint, now part of Anthem, before moving to Baucus’ office. She later became a health care aide in the Obama administration, before spending nearly seven years as a vice president for pharmaceutical giant Johnson & Johnson.

Neither Anthem nor Johnson & Johnson are currently active in the DCE market. But considering other major insurers like Humana are pursuing DCE contracts, and that Anthem already offers Medicare Advantage plans, it is conceivable that these insurance giants could get into the business at some point in the future.

In a February 24 press call announcing ACO REACH, CMS Administrator Jonathan Blum said that the Biden administration had always been committed to continuing with the DCE program.

“We want to make sure that we see these programs as continuing to grow… we have had many conversations with the public and with stakeholders that started with the new CMS team coming on board,” said Blum. “We have felt from the start that we needed to make sure that CMS continues this journey.”

Blum served as the deputy administrator and later principal deputy administrator of CMS under Obama, before joining CareFirst BlueCross BlueShield as an executive vice president, according to Legistorm.

Fowler and Blum’s boss, CMS administrator Chiquita Brooks-Lasure, is a former health care partner at Manatt, Phelps & Phillips, a lobbying firm that worked to launch Medicare Advantage plans as recently as 2020.

Manatt, Phelps & Phillips also played an integral role in reducing fines for nursing home violations in California by as much as 99.9 percent in the middle of the COVID-19 pandemic.

The agency declined requests for comment.

A Dangerous New Stage Of Medicare Privatization

Kip Sullivan, an attorney who is active with Physicians for a National Healthcare Program, said that the DCE program relies on ensuring that elderly or disabled patients don’t have an informed choice about enrolling in the private health care plans.

“Seniors have been swept into DCEs without their knowledge,” he said. “Many — probably most — beneficiaries are in traditional Medicare as opposed to Medicare Advantage because they did not want to be in a plan run by an insurer.”

Sullivan pointed out that the publicly traded DCEs, like Oak Street Health, brag in investor filings that between 13 and 30 percent of the money they get from Medicare goes into profits. By comparison, according to Sullivan, traditional Medicare plans have overhead of just 2 percent.

“When Medicare passed in 1965, there was never an intention to enrich the insurance industry,” he said. “But that’s exactly what’s happening.”

Weisbart, from the Missouri chapter of PNHP, is especially concerned that the Medicare and Medicaid agency “does not need to get congressional consent, discussion or approval for any of these programs. They’re able to do it on their own.”

Under Trump, the agency even issued a waiver that exempts DCE programs from anti-kickback rules that normally prohibit doctors from entering their patients into such for-profit plans. As a result, doctors can be compensated for involuntarily entering their patients into DCE programs.

In recent months, advocates have been waging a full-court campaign against the DCE scheme. In January, 54 members of the House submitted a letter voicing similar concerns to Health and Human Services Secretary Xavier Becerra and CMS Administrator Brooks-Lasure.

What then, explains the Biden administration’s recent decision to expand the program?

As always in our campaign finance system, money could play a role. In 2020, the leadership of DCE contractor Clover Health donated $500,000 to the main super PAC for Senate Democrats, while the company’s financier Chamath Palihapitiya donated $750,000 to the same super PAC plus $250,000 to the Biden Victory Fund.

One Medical — which employed Suzanne Gordon’s doctor and owns Iora Health, the company that tried to enroll her in a DCE -— is backed by the Carlyle Group, a prodigious donor to both parties. Biden enjoyed Thanksgiving dinner last year at the $30 million Nantucket home of Carlyle co-founder David Rubenstein.

Bill Kadereit, the President of the National Retiree Legislative Network, said that the DCE program could usher in a dangerous new stage of Medicare privatization.

“Medicare Advantage plans have failed,” he said. “Privatization has failed. The cost of Medicare is doubling every ten years because of the health care sector campaign contributions. We’re seeing the disassembly and destruction of our precious public health system. Every place where the profiteers have stepped in costs have gone up and health outcomes have gone down.”

https://www.levernews.com…

WDET, Detroit Today, March 22, 2022

Many in this country struggle to understand their health care plan, and feel they don’t have much agency in choosing it. The United States has a patchwork of plans that contributes to more spending on health care than any other developed nation. And yet, many influential and powerful people advocate against single-payer health care.

For many years, the American Medical Association has been that kind of institution as it helped wreck former President Harry Truman’s 1950s universal health care bill that otherwise had majority support from Americans. But in recent years, the association has been showing signs that it may be changing its tune.

---

Dr. Clifford Marks is an emergency-medicine resident at Mount Sinai Hospital in New York. He recently wrote a piece in The New Yorker about a younger generation of doctors that are advocating for universal health care coverage.

He says younger physicians have to contest with large industries, including pharmaceutical companies, hospital systems and insurance systems, which are all difficult to navigate.

“When you have to slog through pre-authorizations, suddenly single-payer health care, I think, seems a lot more appealing,” says Marks.

---

Longtime PNHP member Dr. Peter Orris calls in to the program at 13:43, and a graduating fourth-year medical student named Ryan calls in to the program at 34:07.

https://wdet.org…