PNHP

Healthcare and Racial Justice

Healthcare and Racial Justice

Systemic Change Is Needed for a More Equitable Health System

Developed by the Campaign for NY Health and the Black, Puerto Rican, Hispanic and Asian Legislative Caucus, May 4, 2022

This report compiles national and New York State level data to illustrate that health care access is a critical racial equity issue and how systemic solutions like a universal, single-payer health plan will significantly improve health care access and health outcomes for all.

Key findings

Black, Indigenous and People of Color (BIPOC) were disproportionately harmed by COVID-19 due to an unequal ability to access quality, affordable health care and long before the start of the pandemic, were more likely than white people to be uninsured and to struggle with medical costs.

Black Americans are 10% less likely to hold employer-sponsored health coverage than their white counterparts. Having high-quality health insurance is directly related to whether patients seek care. 

Many BIPOC work and live in environments that impose higher risks of exposure to COVID-19. Only 17% of Latinx workers and 20% of Black American workers have jobs that permit working remotely, while 30% of white workers can do so.

The U.S. has the highest maternal mortality rate in the industrialized world. Black women are three times more likely – and in New York City, 12 times more likely – to die from a pregnancy-related cause than white women. 63% of these deaths are preventable. Uninsurance and under-insurance are major drivers of the U.S. maternal and child mortality rate.

Public health insurance programs play a major role in providing affordable care and better outcomes, especially for Black Americans.

Insurance coverage increases access to care, but being enrolled in an insurance plan does not guarantee timely care or affordability. Nearly half (46%) of insured adults report difficulty affording their out-of-pocket costs and one in four (27%) report difficulty affording their deductible. About 6 in 10 Black and Hispanic adults (58% each) report delaying or skipping at least one type of medical care in the past year due to cost, compared to half (49%) of white adults. Differences in reimbursement rates between private insurance and public insurance create a disincentive for providers to see lower income patients.

Having health insurance lowers the likelihood of medical debt and the amount owed, but even households with health insurance are at risk of incurring medical debt. 17.4% of households with insurance have medical debt compared to 27.9% of households without insurance. Among those with debt, households with health insurance have an average of $18,827.25, while households without health insurance have an average of $31,947.87.

Black households are more likely to hold medical debt. 27% of Black households hold medical debt compared to 16.8% of non-Black households. Medical debt can appear on a person’s credit reports and lower their credit scores, reducing access to credit and making it harder to find a home or a job.

Communities with majority Black and Latinx residents experience provider shortages more than other communities all over the country. Unequal reimbursement rates lead to disparities in access to hospitals and providers. 

Polling consistently shows that voters across race and party lines support systemic change to address shortcomings in the health care system. New York voters overwhelmingly see government as the key stakeholder that should act to address health system problems and support measures to make health care affordable and accessible.

Conclusion

A universal system of publicly-funded, guaranteed health care, often referred to as “single-payer health care,” is the most equitable and affordable way to achieve comprehensive coverage for all. Universal single-payer health care will end the burden of medical debt that disproportionately harms BIPOC communities by eliminating cost-sharing – the out-of-pocket costs such as copays that act as financial barriers to care. Bringing all residents into a single public plan would eliminate the inequity in access that results from a fragmented system. Campaign for New York Health recommends universal single-payer health care as a policy intervention to create a health system that promotes racial equity and quality care for all.

https://www.nyhcampaign.org…

Obama, Obamacare & Disinformation

Summary: We hear lots, including from former President Obama, about the serious problem of disinformation stoked by social media algorithms, polarizing our society. What we hear less about is disinformation regarding private health insurance that comes from both Dems and the GOP and that compromises our ability to get care. We must address both.

‘Regulation has to be part of the answer’ to combating online disinformation, Barack Obama said at Stanford event, Stanford News, April 21, 2022, by Melissa De Witte, et al.

Former U.S. President Barack Obama delivered a keynote address about how information is created and consumed, and the threat that disinformation poses to democracy.

Obama told a packed audience of more than 600 people in CEMEX auditorium – as well as more than 250,000 viewers tuning in online – that everyone is part of the solution to make democracy stronger in the digital age and that all of us – from technology companies and their employees to students and ordinary citizens – must work together to adapt old institutions and values to a new era of information. “If we do nothing, I’m convinced the trends that we’re seeing will get worse,” he said.

During the 1960s and 1970s, the American public tuned in to one of three major networks… “When it came to the news, at least, citizens across the political spectrum tended to operate using a shared set of facts – what they saw or what they heard from Walter Cronkite or David Brinkley.”

Fast forward to today, where everyone has access to individualized news feeds that are fed by algorithms that reward the loudest and angriest voices (and which technology companies profit from). “You have the sheer proliferation of content, and the splintering of information and audiences,” Obama observed.

Facts are competing with opinions, conspiracy theories, and fiction.

“Solving the disinformation problem won’t cure all that ails our democracies or tears at the fabric of our world, but it can help tamp down divisions and let us rebuild the trust and solidarity needed to make our democracy stronger,” Obama said.

The responsibility also lies with ordinary citizens, the former president said. “We have to take it upon ourselves to become better consumers of news – looking at sources, thinking before we share, and teaching our kids to become critical thinkers who know how to evaluate sources and separate opinion from fact.”

Republicans Have Stopped Trying to Kill Obamacare. Here’s What They’re Planning Instead, Politico, April 26, 2022, by John E. McDonough

So it doesn’t take a lot of effort to observe an active health policy ecosystem on the right that is busy recycling and developing ideas that would influence the direction of health policy in a future Republican-dominated federal government. Most of their attention focuses on the employer and individual commercial health insurance markets and the federal-state “marketplaces/exchanges” — the ACA-created entities where individuals and small employers can buy health insurance, ironically a model adapted by Democrats from a Heritage Foundation idea pioneered in the 1990s and early 2000s.

The result would be a system with more options and fewer guarantees. Giving employees less money to cover slimmed-down health insurance will lead many workers to forego coverage entirely. Are conservative politicians prepared to look the other way when they develop serious diseases and have no way to pay for care?

The two behemoths of federal health policy, Medicare for senior citizens and many disabled, and Medicaid for low-income households of every variety, are far less the reform target of Republicans and conservatives than they used to be. An essential reason for this is that both programs, with little controversy, have become increasingly privatized.

Indeed, a small and growing chorus of voices now suggest that Medicare Advantage could be the foundation for a unitary and reformed national health system, not Sanders’ “Medicare for All” which would eliminate Part C, but “Medicare Advantage for All” that would eliminate Medicare A and B, and make Part C universal.

In sum, conservative and Republican health policy voices, in spite of a full retreat on ACA repeal, are active and ambitious to reengage if and when Republicans retake the Senate and/or the House. This is especially true regarding private commercial health insurance, inside or outside of the ACA’s health marketplace/exchanges. They are ready to confront any and all threats to the growing hegemony of Medicare Advantage and to find new opportunities to expand it. They stand on the sidelines regarding fast-growing interest in health care equity and social determinants of health. They are down for the current moment and will be back with ideas and plans when the political climate changes. If prior history matters, so will their emerging ideas.

Comment:

By Don McCanne, M.D.

Much of the noise around disinformation today stems from the misuse of online social media technology such as Twitter and Facebook. The massive threat that this disinformation poses led Barack Obama to speak on the issue in a conference at Stanford University. Although the hype has been about the technology, we should also be concerned about the transmission and misapplication of disinformation regardless of dissemination paths.

Look at our health care system. Is it suffering from disinformation propagated by social media, or is its failure due to disinformation spawned by political ideology and transmitted via all sorts of communication channels?

Obamacare is a system established by the Democrats built on a foundation of a Republican concept of federal-state marketplaces/exchanges. The public Medicare program established by Democrats is now well on its way to becoming private Medicare Advantage plans, and Medicaid is also largely taken over by private insurers. These are Republican concepts being implemented by Democrats. It is difficult to see how disinformation has not played a major role – not the disinformation that Obama addresses in this speech, but his administration’s disinformation about health policy. It brought us today’s flawed health care financing.

Obama is right when he says that all of us must work together to adapt old institutions and values to a new era of information. That means out with the old disinformation, and in with valid health policy science. An essential feature of valid health policy science is truth. Out with fiction; in with facts. Those of us at HJM and Physicians for a National Health Program stand ready to help you sort out and discard the rampant disinformation that has permeated our health care system so that we can implement a system of health care justice for all.

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.

The Policy Dominance of Universal Health Coverage

Researchers trace the history and growing influence of Universal Health Coverage as a policy that does not assure equal access to health services

FOR IMMEDIATE RELEASE: May 2, 2022

(Boston)—What policy is the best approach for developing health systems in low- and middle-income countries?

Researchers at Boston University School of Medicine (BUSM) and the University of New Mexico report that Universal Health Coverage (UHC) has come to dominate discussions around how best to reform low- and middle-income countries’ (LMIC) health systems.

The researchers believe these findings are important because UHC reforms don’t necessarily entail equal and equitable access to services for the entire population regardless of ability to pay, as is the case in other possible health system reforms such as National Health Services that provide care without insurance companies involved or copayments that block access.

The study examined the history of UHC and found its popularity stemmed from the concerted efforts of multiple institutions such as the World Bank, International Monetary Fund and World Health Organization.

“The roots of UHC can be traced to policies enacted by international financial institutions such as the World Bank and International Monetary Fund during the latter half of the twentieth century that caused the debt of low- and middle-income countries (LMIC) to rise precipitously and public sector services to become underfunded,” explains corresponding author Daniel Smithers, a fourth-year medical student at BUSM.

According to Smithers, these same institutions and others such as the World Health Organization (WHO) then advocated for UHC as a method for reforming the health systems of LMICs. Generally, UHC implies a financial reform in which health insurance is expanded in varying degrees to segments of a population and can entail the involvement of private for-profit corporations in the provision of health insurance.

Using both quantitative and qualitative analysis, the researchers found that UHC was mentioned in the health policy literature far more frequently than other health policy options that entail public funding and delivery of health services. When UHC was mentioned in a publication, more than 40 percent of the time the definition used by the authors was sufficiently vague that the definition could be open to misinterpretation or misunderstanding by less informed readers.

The study looked at not only whether UHC was defined in a paper, but also how it was defined. Greater than 40 percent of definitions mentioned finances with respect to UHC, and definitions focused almost entirely on individual-level financial issues. However, these discussions did not suggest that individuals should face no out-of-pocket costs, such as copayments, nor did they touch on other financial aspects of health system reforms such as global budgeting or socialization of health insurance. Over a quarter of definitions also discussed tiering of benefits which could entail differing benefits for the poor and non-poor.

“When a policy such as UHC predominates in the literature to this extent, it’s very important to examine its history critically, how it’s defined, and who’s involved in pursuing it. Policy isn’t crafted in a political, economic or social vacuum,” added Smithers, who in June will start his internal medicine residency in Boston at Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School.

“There are many other organizations advocating for equitable health system reforms in LMICs beyond the dominant transnational organizations such as the World Bank and WHO,” said senior author Howard Waitzkin, PhD, MD, a Distinguished Professor Emeritus at the University of New Mexico. “The People’s Health Movement, the Latin American Social Medicine Association (ALAMES), and Physicians for a National Health Program in the United States are organizations that advocate for alternative health system reforms such as Health Care for All, a single national health program in which access and services don’t differ for any groups in a population. It’s imperative that arguments for UHC not detract attention from these more fundamental and equitable ways to assure universal access to care.”

These findings appear online in the journal Social Science & Medicine.

Smithers DJ, Waitzkin H. Universal health coverage as hegemonic health policy in low- and middle-income countries: A mixed-methods analysis. Social Science & Medicine, https://doi.org/10.1016/j.socscimed.2022.114961

Abstract

Universal health coverage (UHC) has become an influential global health policy. This study asked whether and to what extent UHC became a “hegemonic” health policy. The article consists of three parts: a historical timeline of UHC’s rise, a bibliometric analysis of UHC in the literature, and a qualitative thematic analysis of how UHC is defined and the thematic content of those definitions. The roots of UHC can be traced to policies enacted by international financial institutions (IFIs) such as the World Bank and International Monetary Fund (IMF) during the latter half of the twentieth century. These policies caused the debt of low- and middle-income countries (LMICs) to rise precipitously and led the same IFIs and other institutions like the World Health Organization to become involved in the development and restructuring of health systems. UHC was presented as the leading method for financing development of health systems. As the bibliometric analysis shows, UHC has come to predominate in the literature around health system reforms. The thematic analysis based on a random selection of papers obtained in the bibliometric component of the study shows that often the term is not defined or only poorly defined. There is wide variation in the definitions, with many papers mentioning concepts such as quality, access, and equity without further clarification. Usually, papers define UHC to include tiering of benefits, with discussions of financing that focus on preventing “catastrophic [individual] expenditures” rather than discussing universal budgeting of a national health care system or national health insurance. We conclude that UHC has become hegemonic within global health policy, to the exclusion of discussions about other approaches to the transformation of health systems that are not predominately based on insurance coverage such as Health Care for All system, a system which provides equal services for the entire population.

Medicare for All Explained Podcast: Episode 76

Interview with Dr. Diljeet Singh

May 1, 2022

President Biden’s recently proposed “Cancer Moonshot” has gynecologic oncologist and PNHP national board member Dr. Diljeet Singh thinking even bigger.

By passing improved Medicare for All, focusing on preventions and treatments that we know work, and directing research dollars based on medical need, Dr. Singh estimates that we could achieve the moonshot’s 25-year goal of reducing cancer death rates by 50 percent in only 10 years…and go much further in the long-term.

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

https://medicareforallexplained.podbean.com

Our Healthcare System Is Making My Patients Sicker

Why we need the New York Health Act.

By Reena Agarwal, M.D., M.P.H.
The River (Hudson Valley, N.Y.), April 28, 2022

For two decades as a primary care doctor at health centers in underserved communities around Westchester and New York City, I’ve encountered too many patients facing tragically unfair barriers to good health. Every day I am frustrated, infuriated, and saddened by an immoral system I can’t fix and can’t escape—until we pass legislation that will prioritize health over profits.

One of my patients has asthma, which would be easy to control if she could afford a simple steroid inhaler, but the cheapest such device is $270 per month—way beyond her means as a single-mother who supports two children as a housecleaner. There are no generic versions available here for the 25 million Americans with asthma. Congressional researchers found that US inhalers can cost 10 to 40 times the average price across 11 peer countries, for exactly the same drug manufactured by the same companies. My patient cannot afford an inhaler that costs more than her weekly rent. Instead, we make do with subpar medications that don’t fully control her asthma. So she ends up going to the ER, an extremely expensive resource for taxpayers, which discharges her with meds that control short-term symptoms. But after those pills run out, she comes back to me—still unable to afford what she so badly needs to maintain her health.

Recently, I saw a patient with diabetes. I was the first doctor he had seen in years. A day laborer who cannot afford health insurance, he paid for his visit out of pocket. Unable to afford doctor visits and medications, he’d been treating his diabetes with herbal remedies, as too many of the 30 million Americans (almost 10 percent of our population) with diabetes do. In-office blood tests showed out-of-control glucose levels. My staff and I spent the day calling neighborhood pharmacies, checking prices of insulin and diabetes supplies for him.

This is an absolute waste of his and our time. The cost of insulin has skyrocketed in the past 20 years as corporations have paid competitors not to produce generics. Given the cost to society and taxpayers for uncontrolled diabetes and the ability of modern medicine to help sufferers keep it fully controlled, he should have been able to obtain his medicines at any pharmacy and had the cost fully covered. Failure to do so—the result of how our current system works—makes my patients and their families suffer, and our society less healthy, less productive, and less community-oriented.

And even for those who have insurance, a recent statewide survey of New Yorkers concluded that about half skip taking medications or seeing doctors because of cost.

Thinking about all these inadequately treated patients makes me so angry. Why do we as doctors have to jump through so many hoops to get patients what they need? Most medical offices and hospitals have many more staff dedicated to calling insurance companies about red tape than they have doctors.

This is why I am urging our legislators in Albany to pass the New York Health Act. It will guarantee equitable access to high-quality health care for every New York resident. It would include primary, preventive and specialty care, hospitalizations, mental health, dental, vision, and more. Every New Yorker would pay an affordable amount based on annual income. This legislation, which has majority support in both houses, would finally allow my patients to access needed care with no out-of-pocket barriers. It will also allow the state to negotiate volume discounts on drugs, like the Veterans Administration, which achieves price discounts of 50 percent or more.

As a physician who treats patients in desperate need of care every day, it’s heartbreaking to care for people who struggle to afford ordinary health care. It’s frustrating to spend hours seeking the lowest prices on common medications, without which my patients could die.

The New York Health Act can save taxpayers, patients, and doctors time, money, and suffering—while providing more and better health care, healthier and more productive lives. I will be joining physicians, nurses, students, midwives and more in Albany on May 3, imploring lawmakers to pass this life-saving legislation before the end of this session. We can’t afford to wait any longer.

Dr. Reena Agarwal is a primary care physician and board member of Physicians for a National Health Program, New York Metro chapter.

https://therivernewsroom.com…

Medicare Advantage Is a Massive Scam

The program rips off both the taxpayer and its own enrollees.

By Ryan Cooper
The American Prospect, April 29, 2022

If you’ve ever watched cable news, where the average viewer is in their late sixties, you’ve probably seen an advertisement for a Medicare Advantage plan. They usually star some washed-up celebrity whose career peaked right around when today’s retirees were young adults (think Jimmy Walker or Joe Namath). And they always make a lot of big promises about how great Medicare Advantage coverage is.

There’s just one problem: The sales pitch is an abject lie. Medicare Advantage is much worse than traditional Medicare for people on the program and costs a great deal more to boot. But unless the Biden administration changes course, private companies will soon devour the rest of the program.

Medicare Advantage plans are typically a combination of “Medigap” plans, which cover services not included in the government plan like vision and dental, plus a privatized version of traditional Medicare. About 28 million American seniors are now on Advantage plans, or about 40 percent of the whole program. As Barbara Caress explains in the Prospect, it was set up back in the late 1990s as a way for those wonderful private insurance companies we all know and love to work their free-market magic on one corner of the system America carved out as publicly run. Once we got business involved, surely the quality of coverage would improve and costs would go down, right?

The problem with this logic, as people realized even back in the glory days of neoliberalism, is that there are a lot of perverse financial incentives in health insurance, particularly when it comes to seniors. Half the reason the government set up Medicare in the first place was that as people reach the end of life, they tend to become sick and require more treatment than they can personally afford. In the pre-Medicare days, private companies did all they could to keep them off the insurance rolls.

Introducing the profit motive into Medicare has led to considerable hoop-jumping just to prevent such cravenness. For instance, if the government were to calculate the average per-person cost of Medicare and pay private companies that much per enrollee, companies would scramble to snap up all the younger, healthier seniors with relatively few problems, and cream off some easy profits. As Matt Bruenig explains, that’s why the Centers for Medicare & Medicaid Services maintains a gigantic database of every single one of the roughly 64 million Medicare enrollees, and assigns them all a risk score based on their demographic and health characteristics. Advantage companies then get paid, in theory at least, according to how sick their risk pools are.

That is just one of scores of rules and regulations the government puts out to try to make these private companies behave. It’s a hugely expensive and difficult undertaking, and it turns out that it basically doesn’t work. The results have been exactly the opposite of free-market nostrums: worse coverage that costs more.

One rip-off strategy insurers use is improperly denying claims. A recent investigation from the Department of Health and Human Services inspector general found that companies improperly denied 13 percent of prior authorization requests, and refused to pay 18 percent of legitimate claims—or about 85,000 requests and 1.5 million payments, just in 2019. Paying lots of claims adjusters to fake up reasons to deny necessary treatment is a big reason why Advantage companies spend nearly 14 percent of their money on administration, as compared to traditional Medicare’s 2 percent.

Another strategy is rigging the risk pool. Advantage companies are notorious for pushing doctors to “upcode” as many diagnoses onto their patients as possible, thus increasing their risk score and payment, without having to pay for more treatment. That tactic alone cost the government $9 billion in 2019.

All this (plus a bunch of other complicated scams) means that Advantage enrollees receive something like 10 to 25 percent less in health care spending, but the program costs the government about 3 percent more per person than traditional Medicare. This absurd situation is actually getting worse. One recent study found that Advantage plans cost the government $106 billion in overspending from 2010 to 2019, and nearly a third of that came in just the last two years. The price tag is predicted to balloon to $600 billion over the next nine years.

One would think that the Biden administration would be looking to reverse course, but it isn’t. On the contrary, as Caress notes, it has so far proceeded with a Trump-era plan to privatize the remaining shreds of Medicare by letting private companies serve as payment middlemen through something the Trump team called “direct contracting.”

After an outcry from progressives, the administration altered the privatization plan, mainly changing the name (it’s now called ACO REACH), with the supposed goal of achieving “equitable outcomes.” But as Diane Archer explains at Social Security Works, at bottom it’s still the same idea, with a lot of obvious loopholes for quick profits by denying care, pushing more people into Advantage plans, gaming risk scores, and so on. Unless Biden changes his mind, America is going to let a bunch more foxes into the Medicare henhouse, including private equity firms, and half-heartedly try to limit the damage to the taxpayer with a bunch of ultra-complicated regulations of the type that are failing right before our eyes.

Medicare was a decent initial sketch of a health care system when it was set up back in the 1960s, but it had many bad design elements and left much out. Instead of fixing the problems directly, policymakers have attempted to either coax private companies to do it for them over and over, or simply give out corrupt handouts to their business cronies. The result has been worse coverage and skyrocketing spending that inflated up a huge industry of ruthless corporate parasites. Now those same companies have dragon hoards of government cash to spend on advertising to trick trusting retirees and lobby Congress.

In a sense, the free-marketeers of the 1990s were right to be skeptical of the government’s regulatory capacity. As we have seen, it has been consistently defeated by health care interests in its attempts to prevent profiteering. But that is all the more reason not to burden it with the most complicated health care regulations in the world. Big and simple is what the American state does best. An upgraded, streamlined Medicare that kicked out all the private companies, covered every type of medicine, and enrolled all Americans from birth would fit the bill nicely.

https://prospect.org…

Is single-payer health care possible in the U.S.?

Panel featuring Dr. Johnathon Ross

All Sides with Ann Fisher, WOSU, April 29, 2022

Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system. The results of a 2020 Pew Research Study show there’s an increase in people saying health insurance should be provided by a single, national program.

The American Medical Association (A.M.A.) has long been an opponent of progressive health care reform, however, a younger generation of doctors are advocating for universal health care coverage.

We’ll look at whether single-payer health care is possible in the U.S.

Guests:

https://news.wosu.org…

Medicare Advantage Plans Denying Appropriate Care

Summary: This report from the US Dept of Health and Human Services Inspector General quantifies the high frequency of unjustified denials of care authorizations and payments by Medicare Advantage plans. This is private insurers maximizing profits at the expense of patients.

Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care, Office of Inspector General, US Dept of Health and Human Services, April 2022

What OIG Found:

Our case file reviews determined that MAOs sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules. MAOs also denied payments to providers for some services that met both Medicare coverage rules and MAO billing rules. Denying requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers. …

Prior authorization requests. We found that among the prior authorization requests that MAOs denied, 13 percent met Medicare coverage rules—in other words, these services likely would have been approved for these beneficiaries under original Medicare (also known as Medicare fee-for-service). We identified two common causes of these denials. First, MAOs used clinical criteria that are not contained in Medicare coverage rules (e.g., requiring an x-ray before approving more advanced imaging), which led them to deny requests for services that our physician reviewers determined were medically necessary. …

Second, MAOs indicated that some prior authorization requests did not have enough documentation to support approval, yet our reviewers found that the beneficiary medical records already in the case file were sufficient to support the medical necessity of the services.

Payment requests. We found that among the payment requests that MAOs denied, 18 percent met Medicare coverage rules and MAO billing rules. Most of these payment denials in our sample were caused by human error during manual claims-processing reviews (e.g., overlooking a document) and system processing errors (e.g., the MAO’s system was not programmed or updated correctly).

Comment:

By Don McCanne, M.D.

The private insurance companies have been very successful at marketing their private Medicare Advantage plans as a substitute for traditional Medicare under the Part C Medicare program. Since they are paid on a capitation basis rather than fee-for-service, once patients are enrolled, the insurers can increase their profits by denying requests for prior authorization of legitimate services or by simply denying payment for services that have already been provided in compliance with the rules. Prior studies have demonstrated that they do both, and this study from the OIG confirms that they continue to do so.

Mind you, these are legitimate services for which the insurers have already been paid through capitation. Keeping government funds under their control for their own profits that rightfully should be directed elsewhere (the insurance function) is dishonest. Regardless, the government has allowed the insurers to continue to market these plans in a manner that has resulted in ever increasing diversion of public funds to the private insurers through higher sales of Medicare Advantage plans.

Traditional Medicare can offer the same services for lower administrative costs and without the necessity to include extra charges for profits. Any extra benefits that would be appropriate for the Medicare Advantage plans would also be appropriate for traditional Medicare as well. The Medicare Advantage plans should be eliminated and the traditional Medicare program should be modified to provide the best deal for the Medicare beneficiaries and the taxpayers.

Haven’t we said this often enough? Why aren’t Congress and the Administration responding?

http://healthjusticemonitor.org…

Editor’s note: This behavior by private insurers is part of a broad societal trend favoring the rich. Today Heather Cox Richardson reviews our country’s historical cycling of rights for the many vs. for the few. We are living through a wealth inequality ascendant phase, on the cusp of oligarchy / fascism. Her analysis is critically important. It is imperative to reverse the trend, with real health care reform part of the solution. – JGK

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 Plans Often Deny Needed Care, Federal Report Finds

Investigators urged increased oversight of the program, saying that insurers deny tens of thousands of authorization requests annually.

By Reed Abelson
New York Times, April 28, 2022

Every year, tens of thousands of people enrolled in private Medicare Advantage plans are denied necessary care that should be covered under the program, federal investigators concluded in a report published on Thursday.

The investigators urged Medicare officials to strengthen oversight of these private insurance plans, which provide benefits to 28 million older Americans, and called for increased enforcement against plans with a pattern of inappropriate denials.

Advantage plans have become an increasingly popular option among older Americans, offering privatized versions of Medicare that are frequently less expensive and provide a wider array of benefits than the traditional government-run program offers.

Enrollment in Advantage plans has more than doubled over the last decade, and half of Medicare beneficiaries are expected to choose a private insurer over the traditional government program in the next few years.

The industry’s main trade group claims people choose Medicare Advantage because “it delivers better services, better access to care and better value.” But federal investigators say there is troubling evidence that plans are delaying or even preventing Medicare beneficiaries from getting medically necessary care.

The new report, from the inspector general’s office of the Health and Human Services Department, looked into whether some of the services that were rejected would probably have been approved if the beneficiaries had been enrolled in traditional Medicare.

Tens of millions of denials are issued each year for both authorization and reimbursements, and audits of the private insurers show evidence of “widespread and persistent problems related to inappropriate denials of services and payment,” the investigators found.

The report echoes similar findings by the office in 2018 showing that private plans were reversing about three-quarters of their denials on appeal. Hospitals and doctors have long complained about the insurance company tactics, and Congress is considering legislation aimed at addressing some of these concerns.

In its review of 430 denials in June 2019, the inspector general’s office said that it had found repeated examples of care denials for medical services that coding experts and doctors reviewing the cases determined were medically necessary and should be covered.

Based on its finding that about 13 percent of the requests denied should have been covered under Medicare, the investigators estimated as many as 85,000 beneficiary requests for prior authorization of medical care were potentially improperly denied in 2019.

Advantage plans also refused to pay legitimate claims, according to the report. About 18 percent of payments were denied despite meeting Medicare coverage rules, an estimated 1.5 million payments for all of 2019. In some cases, plans ignored prior authorizations or other documentation necessary to support the payment.

These denials may delay or even prevent a Medicare Advantage beneficiary from getting needed care, said Rosemary Bartholomew, who led the team that worked on the report. Only a tiny fraction of patients or providers try to appeal these decisions, she said.

“We’re also concerned that beneficiaries may not be aware of the greater barriers,” she said.

Kurt Pauker, an 87-year-old Holocaust survivor in Indianapolis who has kidney and heart conditions that complicate his care, is enrolled in a Medicare Advantage plan sold by Humana.

In spite of recommendations from Mr. Pauker’s doctors, his family said, Humana has repeatedly denied authorization for inpatient rehabilitation after hospitalization, saying at times he was too healthy and at times too ill to benefit.

Last March, after undergoing hip surgery, Mr. Pauker was again told that he did not qualify for inpatient rehab but would be sent back to a skilled nursing center to recover, his family said.

During his previous stay at a skilled nursing center, he received little in the way of physical or occupational therapy, the family said. He has so far lost his appeals, and relatives have chosen to pay for care privately while continuing to pursue his case.

People “should know what they’re giving up,” said David B. Honig, a health care lawyer and Mr. Pauker’s son-in-law. People signing up for Medicare Advantage are surrendering their right to have a doctor determine what is medically necessary, he said, rather than have the insurer decide.

Humana, which reported strong earnings on Wednesday, said it could not comment specifically on Mr. Pauker’s case, citing privacy rules. But the insurer noted that it was required to follow the standards set by the Centers for Medicare and Medicaid Services.

“While every member’s experience and needs are unique, we work to provide health coverage that is consistent with what we believe C.M.S. would require in each instance and supports our members in achieving their best health,” Humana said in a statement.

Medicare officials said in a statement that they are reviewing the findings to determine the appropriate next steps, and that plans found to have repeated violations will be subject to increasing penalties.

The agency “is committed to ensuring that people with Medicare Advantage have timely access to medically necessary care,” officials said.

The federal government pays private insurers a fixed amount per Medicare Advantage patient. If the patient’s choice of hospital or doctor is limited, and if he or she is encouraged to get services that are less expensive but effective, then the insurer stands to profit.

Under traditional Medicare, there may be an incentive for hospitals and doctors to overtreat patients because they are paid for each service and test performed. But the fixed payment given to private plans provides “the potential incentive for insurers to deny access to services and payment in an attempt to increase their profits,” the report concluded.

Dr. Jack Resneck Jr., the president-elect of the American Medical Association, said the plans’ denials had become widespread. The organization has been aggressively lobbying lawmakers to impose stricter rules.

Prior authorization, intended to limit very expensive or unproven treatments, has “spread way beyond its original purpose,” Dr. Resneck said. When patients cannot get approval for a new prescription, many do not fill it and never tell the doctor, he added.

Appeals end up unfairly burdening patients and often take precious time, some doctors said.

“We are able to reverse this some of the time,” said Dr. Kashyap Patel, a cancer specialist who serves as chief executive of Carolina Blood and Cancer Care and president of the Community Oncology Alliance. But his efforts to “fight like a hawk” to get approvals for the care he recommends also leave him less time to tend to patients, he added.

The most frequent denials found by the investigators included those for imaging services like M.R.I.s and CT scans. In one case, an Advantage plan refused to approve a follow-up M.R.I. to determine whether a lesion was malignant after it was identified through an earlier CT scan because the lesion was too small. The plan reversed its decision after an appeal.

In another case, a patient had to wait five weeks before authorization to get a CT scan to assess her endometrial cancer and to determine a course of treatment. Such delayed care can negatively affect a patient’s health, the report noted.

But Advantage plans also denied requests to send patients recovering from a hospital stay to a skilled nursing center or rehabilitation center when the doctors determined that those places were more appropriate than sending a patient home.

A patient with bedsores and a bacterial skin infection was denied a transfer to a skilled nursing center, investigators found. A high-risk patient recovering from surgery to repair a fractured femur was denied admission to a rehab center, although doctors said the patient needed to be under the supervision of a physician.

In some cases, the investigators said Medicare rules — like whether a plan can require a patient to have an X-ray before getting an M.R.I. — needed to be clarified.

The plans may use their own clinical criteria to judge whether a test or service should be reimbursed, but they have to offer the same benefits as traditional Medicare and cannot be more restrictive in paying for care.

The investigators urged Medicare officials to beef up oversight of Advantage plans and provide consumers “with clear, easily accessible information about serious violations.”

https://www.nytimes.com…

The American Public Health Association Endorses Single-Payer Health System Reform

By Ben King, Ph.D., M.P.H.; Anthony Spadaro, M.D., M.P.H.; Gordon Schiff, M.D.; Rosa Rodriguez-Monguio, Ph.D., M.S.; Alison O. Jordan, L.C.S.W.; Lisa Flaherty, Pharm.D., M.P.H.; Wei-Chen Lee, Ph.D.; Julie Zito, Ph.D.; Oliver Fein, M.D.
Medical Care, Official Journal of the Medical Care Section, American Public Health Association, April 26, 2022

Abstract

Health care is a human right. Achieving universal health insurance coverage for all US residents requires significant system-wide reform. The most equitable and cost-effective health care system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal health insurance coverage through SP financing, providers can focus on optimizing delivery of services, rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. Rather, with a SP, the people act as their own insurer through a partnership with provider organizations where tax dollars work for everyone. Consumer choice is then based on the best care to meet need with no out-of-pocket payments. SP financing is the best option to ensure equity, fairness, and public health priorities align with medical needs, providing incentives for wellness. Consumer choice will drive market forces, not provider network profits or insurer restrictions. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans developed by providers based on what works best for the patient. In 2021, the American Public Health Association adopted a policy statement calling for comprehensive reforms to implement a SP system. The proposed action steps in this policy will help build a healthier nation, saving lives and reducing wasted health care expenditures while addressing inequities rooted in social, demographic, mental health, economic, and political determinants.

full commentary: https://journals.lww.com…

More Children Now Killed by Guns than Cars

Summary: Since 2017, for the first time, US child and young adult deaths from firearms exceeded those from motor vehicles. Why? Because we’ve improved car safety, and failed abysmally to improve gun safety. Why? Because gun organizations have opposed research and regulation. This must change.

Crossing Lines — A Change in the Leading Cause of Death among U.S. Children, New England Journal of Medicine, April 16, 2022, by Lois K. Lee et al.

Injuries are the most common cause of death among children, adolescents, and young adults between 1 and 24 years of age in the United States; indeed, injuries are responsible for more deaths among children and adolescents than all other causes combined. For more than 60 years, motor vehicle crashes were the leading cause of injury-related death among young people. Beginning in 2017, however, firearm-related injuries took their place to become the most common cause of death from injury. This change occurred because of both the rising number of firearm-related deaths in this age group and the nearly continuous reduction in deaths from motor vehicle crashes. The crossing of these trend lines demonstrates how a concerted approach to injury prevention can reduce injuries and deaths — and, conversely, how a public health problem can be exacerbated in the absence of such attention. Between 2000 and 2020, the number of firearm-related deaths among children, adolescents, and young adults increased from 6998 to 10,186, according to the Centers for Disease Control and Prevention (CDC).

In 2000, motor vehicle-related injuries resulted in 13,049 deaths among young people. Twenty years later, there has been a nearly 40% decrease, with 8234 motor vehicle traffic deaths recorded in 2020.

Although substantial federal funding has been devoted to research on motor vehicle crashes, the firearm industry and gun-rights organizations, led by the National Rifle Association (NRA), have been effective at keeping federal dollars from financing firearm-related research. Between 1996 and 2019, little federal research funding was appropriated for firearm-injury prevention.

Comment:

By Don McCanne, M.D.

We do have some good news. Our industry designed to provide the beneficial essential task of transporting human beings has been effective in reducing injuries and deaths through better design of vehicles and improvement of public safety standards. The industry and our public stewards are to be commended.

On the other hand, we have an industry designed to produce detrimental lethal projectiles, and what do we do? We protect and embellish that industry to the degree that it has moved into first place as the most common cause of death among children and young adults.

Think about that. We sacrifice our children to an industry that many believe does not provide substantial benefit to society. We defer to gun-rights organizations despite broad public support for gun regulation.

Look at the tremendous gains we made with traffic safety – for an enormous industry that is essential to our commerce. The gun industry? Some of us wish it would disappear, but since its preservation seems assured, let’s focus on harm mitigation. The horrendous record on injury and death tells us we’re long past due for accelerated research and regulation to improve safety. Our children deserve no less, especially after seeing the tragic consequences of our decades of delay.

http://healthjusticemonitor.org…

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California Commission Affirms Unified Financing

Summary: The Healthy California for All Commission issued a final report laying out the huge benefits to be derived from “unified financing” – one payment mechanism for all health care. Costs down, health care up. The impressive affirmation of fundamental principles plus technical findings bolster efforts for single payer.

Key Design Considerations for a Unified Health Care Financing System in California, Report to the Healthy California for All Commission, April 2022

[T]he concept of unified financing [UF] describes a statewide system to arrange, pay for, and assure health care in which:

  • All Californians will be entitled to receive a standard package of health care services;
  • Entitlement will not vary by age, employment status, disability status, income, immigration status, or other characteristics; and
  • Distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage will be eliminated within the system of unified financing.

The analysis done in connection with the Commission’s work found that:

  • Under almost all scenarios analyzed, in the first year of implementation unified financing is expected to result in lower total health care expenditures than under the status quo;
  • If, as expected, UF reduces the rate of growth of health spending, savings over time would be achieved under all scenarios examined, even when long-term care services and supports (LTSS) are included as covered services;
  • Assuming that the federal and state governments support UF at the level they would have supported under status quo fragmented financing, the savings from UF will accrue to California employers and households, who will on average pay less to support UF than they pay in the status quo;
  • Financing can be stable over time, but will depend on controlling cost growth and securing agreements with the federal government about the rate of growth in federal payments.

Next Steps …

4. Role of Health Plans: Evaluate whether health plans under the status quo add value by furthering access, affordability, quality and equity while accounting for excessive administrative costs and profits and burden on providers. If health plans are retained and reimagined under UF, what functions would they perform?

5. Uniform Clinical Data Record: [E]xplore the potential benefits …

Comment:

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

Don’t let the precise technical prose fool you – this is a full-throated endorsement of the critical core of single payer: unified financing for universal coverage. That is, replacing our cacophony of insurance products and uninsurance with 100% coverage with standard comprehensive benefits saves money while protecting family health and finances.

The Healthy California for All Commission is an outgrowth of AB 1400, and has been working hard since January 2020, guided by the State of California and supported by University of California experts. The single payer voice within the Commission was strong, and came through in this report’s principles and findings.

Importantly, the report (Fig. 1) confirms that savings from simpler administration and lower drug prices (15.4%) exceed increases in utilization (11%, or 7% if income-related copays). This is the pivotal dynamic and irresistible appeal of unified financing: streamlining permits more health care, with net savings. It is the “free lunch” so rare in economics.

Thus, we move a little closer to single payer. The report lays out important next steps, both technical (e.g., better data on health spending) and bureaucratic / political (e.g., seeking federal waivers and cooperation).

Two tasks from the report excerpt above warrant emphasis:

Role of Health Plans: “excessive administrative costs and profits and burden on providers … if retained and reimagined, what functions?” Exactly. Health plans are an expensive & inexcusable drain on our current system. There is no evidence of net benefit. They should be eliminated entirely (in deference to direct fee-for-service), or radically restructured into claims processors.

Uniform Clinical Data Record: Ooh, I get to talk geeky. Currently we struggle with incompatible electronic health records and claims files. Assembling this information into one integrated data system would enhance patient care, research on treatment effectiveness, and detection of fraud and waste. Gotta love top notch data!

There remain many challenges ahead. But today I feel really good about the great State of California so clearly and unequivocally confirming the principles we’ve been fighting for.

http://healthjusticemonitor.org…

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