Summary: Yesterday was the end of the Roe era of federal protection of abortion rights. This is the culmination of decades of GOP anti-democratic efforts to undo majority-supported and health-enhancing reproductive autonomy.

---

Texas Supreme Court Shuts Down Final Challenge to Abortion Law, New York Times, March 11, 2022, by Kate Zernike and Adam Liptak

---

The Texas Supreme Court on Friday effectively shut down a federal challenge to the state’s novel and controversial ban on abortion after about six weeks of pregnancy, closing off what abortion rights advocates said was their last, narrow path to blocking the new law.

The decision was the latest in a line of blows to the constitutional right to abortion that has prevailed for five decades.

The Texas law, which several states are attempting to copy, puts enforcement in the hands of civilians. It offers the prospect of $10,000 rewards for successful lawsuits against anyone — from an Uber driver to a doctor — who “aids or abets” a woman who gets an abortion once fetal cardiac activity can be detected.

It is the most restrictive abortion law in the nation, and flies in the face of the Supreme Court’s landmark 1973 decision in Roe v. Wade, which prohibits states from banning the procedure before a fetus is viable outside the womb, which is currently about 23 weeks of pregnancy. …

Abortion rights supporters and legal scholars said the Texas law would encourage other states not only to pass similar bans on abortion, but to attempt to nullify other precedents they oppose.

---

Comment:

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

Friday sadly marked the demise of Roe v. Wade, which since 1972 – half a century – protected abortion rights based on privacy protections in the 14^th Amendment to the US Constitution. The end came in the form of a Texas Supreme Court decision rejecting the last legal path to invalidating a state law banning abortion after 6 weeks of pregnancy, even in cases of rape and incest.

This is almost certain to result in a flood of similar laws in other states and further restrictions in Texas, such as prohibiting help for women seeking abortion out of state. The result will be, aside from reversal of reproductive health autonomy for millions of women, the well-documented serious psychological and physical risks associated with taking an unwanted pregnancy to term – far in excess of harms from abortion. Plus the mortality and morbidity risks from unregulated illegal abortions offered in medically suboptimal settings, often by un- or underqualified practitioners. This is a medical and health justice nightmare.

Why does the title blame “GOP subversion of democracy” for this outcome? Because for two decades, the GOP has used profoundly anti-democratic tactics to mold the US Supreme Court into the perfect anti-Roe instrument. How? By stealing elections (mainly) and ignoring long-standing governing and legal norms. Here is a partial list:

2000: The GOP (George W. Bush) steals Florida and thus the presidential election, through a combination of blocking voting for tens of thousands of mostly minority individuals incorrectly listed as having felony convictions, a horribly confusing ballot design in Palm Beach County (a Dem error), and vote recount disruptions and delay orchestrated by Roger Stone. An already GOP US Supreme Court breaks precedent in a decision removing authority over state voting from the state (contradicting conservative legal doctrine) to end the recount while Bush is still ahead.

2004: Swift Boat dirty tricks gets Bush a second term.

2001-2008: Bush appoints 2 Supreme Court Justices.

2016: In mid-February, conservative Justice Antonin Scalia dies. Senate Majority Leader Mitch McConnell refuses to allow a hearing for Obama’s nominee Merrick Garland, despite nearly a year before the next president takes office. This is unprecedented obstruction.

2016: Trump is elected despite getting 2.9 million fewer votes, and with Russian social media support that some analysts believe tipped mid-western states and thus the election to him.

2017-2020: Trump appoints 3 Supreme Court Justices, creating a 6-3 conservative majority.

2021: Texas passes the abortion law, constructed with a novel and frightening legal theory: The state can evade 14^th Amendment constraints on states taking away individual rights by delegating the enforcement of such rights limitations to private citizens via civil litigation. This has been called a “posse” or “vigilante” law – empowering individuals not working for the government to do what the government is not allowed to do. Astoundingly, the US Supreme Court (the conservative majority) permits this approach. This sets the stage for any state to circumvent any federal limits on state action, simply by delegating enforcement to the population.

Thus we see merged a heinous states-rights governing theory, harkening to the 19^th century, with conservative social values. Note: only 27% of Americans wanted Roe over-turned.

The delegation legal approach likely will be used to deny other federally guaranteed rights.

A larger and more balanced Supreme Court is appealing. It can be done.

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.

Summary: California’s Medi-Cal expansion for undocumented immigrants is laudatory … but is just a partial fix, leaving millions uncovered. It falls profoundly short of what is needed to cover everyone with high quality insurance, while saving money and boosting the economy: single payer.

---

California is expanding Medi-Cal – but hundreds of thousands of immigrants will still be left behind, CalMatters, February 28, 2022, by Ana B. Ibarra

---

Experts say allowing people to sign up for comprehensive Medi-Cal coverage regardless of their immigration status is the single biggest step California can take to insure as many people as possible in the current system. Newsom called his latest planned expansion “universal access to coverage.”

But the expansion would still leave several hundred thousand undocumented immigrants uninsured. They are unable to qualify because they have jobs where they earn above Medi-Cal’s annual income thresholds for most adults.

That leaves many low-income immigrants with few viable options for health coverage. While most Californians who earn over the Medi-Cal limit can get subsidized coverage through Covered California, undocumented people are not allowed to buy insurance through the marketplace under the federal Affordable Care Act.

In 2023, after Medi-Cal expands to cover undocumented immigrants 50 and older, about 3.2 million people will remain uninsured in California, according to researchers at the UC Berkeley Labor Center and the UCLA Center for Health Policy Research. Of those, 1.16 million will be unauthorized immigrants.

Even if Newsom’s next step is approved — covering undocumented adults 26 to 49 years old as early as 2024 — that would still leave roughly 450,000 undocumented people under 65 with no health coverage.

Lack of access because of immigration status is just one piece of the remaining uninsured. Many other Californians forgo coverage despite being eligible, likely because of the cost. According to the UC Berkeley and UCLA study, 2 million uninsured people qualify for Medi-Cal, employer coverage or Covered California.

---

Comment:

By Don McCanne, M.D.

Well, so we can’t have single payer reform because it is too expensive, and we can’t afford the taxes to pay for it. But at least we can fill in much of the void in California and other states by providing Medi-Cal (Medicaid) to the undocumented… or can we? Check out the numbers.

Hundreds of thousands of the undocumented in California would still be left out and millions of other Californians would remain uncovered for other reasons, primarily for lack of affordability of insurance. And worse, our highly dysfunctional, fragmented healthcare financing system that shunts much of our healthcare dollars to entrepreneurial interests while impairing access to needed care would remain in place. Defective incremental patches can never serve as an effective substitute for a comprehensive, equitable, publicly administered, affordable, progressively funded program that is truly universal for life.

The recent Nation article by Michael Lighty shows how ridiculous our concern over single payer costs and taxes has been when we could have an ideal single payer system for less money than we are paying for our current inadequate, dysfunctional system. And the recent study from the Congressional Budget Office shows us that spending on a single payer system would not only fix our healthcare financing system and bring comprehensive health care to everyone, it would also provide improvements to the economy that would benefit all of us.

Merriam-Webster’s definition 3b for insanity: “something utterly foolish or unreasonable”

Now there is an instance we can save on healthcare that doesn’t even take a psychiatrist to manage. Let’s just get rid of our current dysfunctional financing system and substitute it with a single payer system. We’ll not only cure our insanity, we’ll be money ahead!

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.

Summary: An excellent commentary in The Nation reviews the cost advantages of single payer in California and generally, the current health care cost explosion, and the unsavory trade-off foisted on us every day: corporate profits up, family health down.

---

The Plan to Save Californians $117 Billion a Year by Switching to Single-Payer, The Nation, February 25, 2022, by Michael Lighty

---

Why is universal health care seen as prohibitively expensive when the status quo costs far more?

In the public debate over Medicare for All, the first casualty is always the truth about costs, savings, and taxes. And the recent struggle in California over a proposed statewide single-payer health care bill, the California Guaranteed Health Care for All Act, has been no exception. Scouring the media coverage of the bill, also known as AB 1400, you would find a multitude of statistics and figures, but nowhere would you find this simple fact: Under the current system, health care in California will cost an estimated $517 billion in 2022. …

Reports from the Healthy California for All Commission, a single-payer health care task force appointed by the state government, estimate that the present system, characterized by huge inequities, coverage gaps, restrictions on access to care, and administrative complexity, will cost an estimated $323–$496 billion more in 2031 than would a single-payer system covering everybody. …

But what about taxes, the favorite scare tactic of those who profit from the current dysfunctional system? According to a study from the Healthy California for All Commission, it turns out that the current cost of health care is the biggest “tax” paid by the middle class—ranging from 25 to 40 percent of a household’s income. Single-payer financing eliminates that burden. Replacing the cost of premiums, co-payments and deductibles with modest public tax increases on businesses and high-income individuals seems like a very good deal. (Under California’s AB 1400, households making less than $600,000 per year would see no more than a 1 percent tax increase.) …

If readers are surprised to hear about the savings from single-payer, chalk it up to the influence of the health care industry, which has been repeating the lie that we cannot afford universal health care since 1993. Because the industry can literally charge whatever it wants now, single-payer represents a direct challenge to its profits and power.

Consider the industry’s ability to set the health policy agenda. Counting lobbying expenditures and campaign contributions, the health care sector spends more on influencing lawmakers than any other industry. A study published in The Journal of the American Medical Association found that between 1999 and 2018 “the pharmaceutical and health product industry spent $4.7 billion, an average of $233 million per year, on lobbying the US federal government; $414 million on contributions to presidential and congressional electoral candidates, national party committees, and outside spending groups; and $877 million on contributions to state candidates and committees.” …

The profits of the biggest health care corporations are obscene: Kaiser Permanente had a net income of $8.1 billion in 2021, a record. The same year, HCA, the largest for-profit hospital corporation, booked $7 billion in profits, while United Health, the largest commercial insurer, reported profits of $17.3 billion. … Meanwhile, patients die for lack of insulin, and Congress has so far failed to limit the price of this decades-old drug (as it has failed to limit the price of any prescription drug, which single-payer will do).

Sifting through the scare tactics, misrepresentations, and influence buying of the health care industry reveals a pattern of profiting from human suffering and protecting financial interests at the expense of our health. California, like the rest of the United States, can both save money and address our health inequities by adopting a single-payer system. Yes, we can afford to provide the health care that we need and deserve. In fact, we can’t afford not to.

---

Comment:

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

My comment is short and sweet – Michael does a stellar job of summarizing favorable single payer cost analyses, rapidly rising healthcare costs in the current system, sky-high industry profits and salaries, political influence through donations and lobbying, and a “pattern of profiting from human suffering and protecting financial interests at the expense of our health.”

This piece is a must-read.

Single payer is a must-do.

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.

Summary: An excellent study using a sophisticated research design (geeks: instrumental variable) finds that Veteran’s Affairs care lowers mortality by nearly half and costs by one-fifth after an emergency visit. Government care beats private care, reminding us of the advantages of a committed and well-run health care system.

---

Is There a VA Advantage? Evidence from Dually Eligible Veterans, Working Paper 29765, National Bureau of Economic Research, February 2022, by David C. Chan Jr et al.

---

Abstract: We study public vs. private provision of health care for veterans aged 65 and older who may receive care provided by the US Department of Veterans Affairs (VA) and in private hospitals financed by Medicare. Utilizing the ambulance design of Doyle et al. (2015), we find that the VA reduces 28-day mortality by 46% (4.5 percentage points) and that these survival gains are persistent. The VA also reduces 28-day spending by 21% and delivers strikingly different reported services relative to private hospitals. We find suggestive evidence of complementarities between continuity of care, health IT, and integrated care.

From the Conclusion: The structure of health care delivery to US veterans provides a distinctive research opportunity, allowing us to study fundamentally different systems of health care that coexist for a large patient population. Specifically, millions of older veterans (those at least age 65) are dually eligible for care in a public system operated by the Veterans Health Administration or in private-sector hospitals financed by Medicare. Our work has current policy relevance, as the Department of Veterans Affairs is now considering whether to bolster its existing public delivery system or to replace it, either partially or entirely, with a system of financing private care.

We find a significant VA advantage. The VA outperforms the non-VA alternative in a wide variety of locations and for all types of patients that we consider. Importantly, the VA also reduces total spending by 21% relative to non-VA providers, which points to higher productivity in the VA than in the private sector. We demonstrate striking differences in the procedures reportedly performed at the VA vs. those reportedly performed by non-VA providers. These differences relate to the underlying arrangements in which public vs. private providers are funded in the US (and other developed countries). For example, veterans with prior VA care (and those who are more likely to use the VA) have larger survival gains from VA assignment.

Our results contribute more broadly to two streams of literature on the efficiency of production. First, we contribute to the descriptive analysis that compares the performance of the US health care system to systems in other developed countries (Blank, Burau, and Kuhlmann 2017). By almost all accounts, comparisons of US health outcomes and health care spending are unfavorable with those of other developed countries (Garber and Skinner 2008; Rice et al. 2013). Our analysis points to a potentially significant source of inefficiency in the US context: its version of private provision of health care. This arrangement rewards costly but not necessarily efficient care. Although several developed countries that outperform the US also feature private provision of care, the US system arguably has the most complex configuration of financing and delivery, with high levels of uninsurance, administrative costs, and fragmentation (Cebul et al. 2008). These well-known information and coordination gaps may be fatal, at least for veterans in emergencies.

Second, we provide empirical support in the context of health care for the general idea of production complementarities among three innovations in production: workplace reorganization, products and services, and information technology (IT). Hospitals without a broad network of clinics and a clear mandate for a population’s health may find it difficult to reorganize and redefine their services to optimize patient health. Complementarities in health care production may pose barriers for replicating the VA advantage in the fragmented private landscape of US health care.

---

Comment:

By Don McCanne, M.D.

With the high costs and gross inefficiencies in how we pay for health care that have left so many without care and with financial hardship, we have been working for decades on reforming the system. Rather than converting health care to a predominantly government owned and operated system, we have left the delivery system owned largely by private non-profit and for-profit entities, while professing to support public financing of care. Yet we are in the process of turning over the administration of Medicare and Medicaid to private entities, with well documented adverse consequences. Private equity firms have moved into health care en masse with the expected dire consequences for health care justice.

Contrast that with the government health care program that lies before our very eyes: the US Department of Veterans Affairs (VA). The government-owned and operated system (i.e., designed and operated coherently) saves lives and reduces costs! Lest one be tempted to challenge the qualifications of the authors, one of them, David Card, was a co-recipient of the 2021 Nobel Prize in Economic Sciences.

We have the money to provide high quality, comprehensive care to everyone. We obviously do not have the correct policies in play. It is time that we take a step back and see where we have gone wrong, and then correct our policies. We are long past due for providing health care justice for all.

http://healthjusticemonitor.org…

---

Editor’s note: Although Medicare-paid services fared worse in this comparison, let’s not blame the funding. Public financing won’t yield top results if private insurers meddle and providers are profit-driven. We need a commitment to access and quality from coverage through care. – 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.

Summary: Today we take a step back to consider a pivotal issue that arises in discussions of health reform generally and single payer specifically: Which is the better way to pay providers – FFS or capitation? The answer is: Both. That is, done right, both can work very well. And, sometimes, neither …

---

Comment:

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

Fee-for-service (FFS) means that providers bill and are paid for each medical service delivered – physician visit, test or intervention, hospital day.

Capitation means that providers are paid a monthly amount per beneficiary for all services or just some (e.g., primary care).

Let’s start with the claim that capitation is better than fee-for-service, full stop. Less costly and with excellent quality of care. This can be true in narrow circumstances. A very experienced provider organization that likes to be paid via capitation, with similar administrative and profit structures as the fee-for-service alternative, can often save money (offer a cheaper alternative) while maintaining quality of and satisfaction with care. Some early HMO history suggests that. It makes sense since some providers will raise their income in a FFS system by increasing the quantity of services.

However, the “similar administrative and profit structure” caveat often distinctly fails in the US. The most important example is Medicare. Traditional Medicare is FFS, and has very low overhead for the funder, CMS. In contrast, Medicare Advantage, the capitated option, uses insurance company intermediaries, with substantial administrative overhead and profits. Medical care costs are lower in Medicare Advantage, but total costs (including the overhead and profits) are substantially higher than FFS Medicare, by one estimate more than $100 billion higher. Quality of care is comparable. Financial barriers to care are higher in Medicare Advantage for individuals in poor or fair health. Perhaps related, sicker patients often shift to FFS. So, in Medicare, FFS is a better option. (Unfortunately, there is currently a process to shift FFS Medicare to fully or semi-capitated direct contracting, see HJM posts starting here.)

In Medicaid, capitation via private insurers has resulted in significant access to care problems.

Relative ease of oversight is a factor favoring FFS. A single payer FFS system facilitates strong rate regulation and use of comprehensive claims / payment data to identify and reduce fraud and waste.

Another consideration is how to pay for capital investments, such as a new hospital. Under both capitation and FFS it matters how operating margins (profits) are used. In our system, net income often feeds expansion. US single payer plans would eliminate this dynamic, removing the funding and/or approval of capital spending from the payment for care. This facilitates investment decisions based on system need rather than provider financial gain. It improves both FFS and capitation.

Looking to other wealthy countries, both FFS and capitation work well. Nearly two thirds of countries in the OECD use FFS payment, solely or in combination with capitation and salaries. Their costs, quality, satisfaction, and outcomes are all much better than in the US. See, for example, specific performance measures and global outcomes.

Of note, capitation in other countries is a different entity than here. For example, in the Netherlands, which relies on capitation, typically < 5% of premium payments go to overhead and profits (here, p.49), and those minimal profits are not retained by owners, instead they’re passed forward to pay for care in subsequent years. (Their “risk adjustment” system is also better, which we’ll discuss another day.)

In three-quarters of other OECD countries, capital spending is regulated by the government.

A key issue in contemplating FFS for single payer: the history of universal coverage suggests that provider supply constraints distinctly limit the jump in utilization from providing everyone very comprehensive insurance. If supply is limited (which it is), it’s impossible to increase services to make more money. So FFS payment does not (can not) result in huge cost increases. See our article. Further, US single payer proposals include system-wide global budgets, as done in other countries, providing a formal mechanism to slow cost growth if necessary.

So, you can see why the main answer is “both” – FFS and capitation both can work well with appropriate structure and regulation.

Finally, the “neither” part. For hospitals, one of the most common and successful payment methods is global budgeting. Each hospital receives a fixed annual allocation based on past services provided, with allowances for growth in utilization and costs. This removes the administrative burden of billing, and allows hospitals to focus on providing services. We’ve written an article on this, available soon.

The other “neither” — as noted above, salaries are also a fine way to pay providers.

The essential features of successful universal coverage are insuring everyone with the same comprehensive coverage, with minimal financial burden, using simple and fair payment systems, and removing profit as a driving force in the system. With the right structure and regulation, any reasonable payment modality can work.

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.

Summary: As the COVID Omicron variant subsides, and schools cautiously reopen, a tiny but vocal group of doctors is arguing to end all precautions, including masking. Their arguments distort public health evidence. Under-vaccinated and under-resourced communities are the most likely to suffer from such a strategy.

---

Why Is This Group of Doctors So Intent on Unmasking Kids? The New Republic, February 22, 2022, by Melody Schreiber

---

There is stark disagreement on the best path to a new normal. While the pandemic still rages, with 25 percent of children 5 to 11 and a little more than half of 12- to 17-year-olds vaccinated, a vocal minority of physicians and scientists has called for the end of precautions. Some of them, organized in a movement they call “the Urgency of Normal,” are finding an eager audience in those who have largely been spared the worst of the pandemic. The group says the precautions, more than the pandemic itself, are causing mental strain and potential harms to children. If the precautions are lifted, kids can return to normal.

Public health experts, meanwhile, point to what they say is a huge flaw in this reasoning: Removing precautions before meeting various vaccination, treatment, and caseload benchmarks could let the virus spread unchecked, develop more dangerous variants, and put “normal” out of reach for much, much longer.

There is, to be clear, little scientific disagreement about what helps quell the pandemic. Vaccinations, masks, ventilation, tests, staying home while sick—these layers of protection, when employed, are highly effective at keeping the virus from spreading, which is especially urgent with 109,000 daily cases, 2,000 daily deaths, and many hospitals still at capacity.

The science is strong. But this movement to drop pandemic precautions is about something else entirely—a potent mix of pandemic fatigue, politics, individualistic thinking, and, if both polling and pandemic statistics are to be believed, a persistent divide based on class and race.

… In the past two weeks, governors have begun rolling back the few state-level mask mandates that existed. …

But the Urgency of Normal group wants to go a step further: ending all precautions for children, permanently.

“… what they did with the mental health science. It’s a true perversion of what science communication is supposed to be,” Black said. “They had mis-cited the CDC…” The Centers for Disease Control and Prevention study found that there was no significant increase in child suicide, yet the group used that study to claim the opposite—an increase in suicide.

Given that the research on masking is pretty favorable to mandates, especially during times of high transmission, the downsides of masking increasingly look political. But even when it comes to politics, anti-maskers run into data problems: Polls show overwhelming support for mask mandates.

The places that could actually attain a sense of normalcy are overwhelmingly high-income, white communities that have long been insulated from the worst effects of the pandemic. And these are the locations with the most support for lifting precautions.

---

Comment:

By Gregg Gonsalves, Ph.D.

This article in The New Republic describes a movement to remove all COVID-19 pandemic mitigation strategies in schools, starting with masking of students, under the tagline of the #urgencyofnormal.

The author describes the leadership of the group as composed of people with limited public health expertise, including Dr. Lucy McBride, a concierge internist in DC; Dr. Scott Balsitis a virologist at the drug company Gilead Sciences, and; a hematologist-oncologist at UCSF, Dr. Vinay Prasad. Despite this, the group has been able to get heavy mainstream media attention, including on CNN and other major cable news outlets.

The #urgencyofnormal movement has largely been targeted at white, wealthy, liberal parents and “particularly focused toward highly vaccinated communities” with a toolkit of advice for parents on how to argue against pandemic mitigation measures.

The problem the article exposes is that the leaders and creators of the toolkit have relied on dubious interpretations and cherry-picking of the science, on masks, the mental health impact of COVID mitigation strategies, and the clinical impact of the disease on children. In addition, with its focus on highly vaccinated communities, the #urgencyofnormal creators have ignored the disparities in vaccination and resources to protect students, teachers and staff in schools outside of wealthy, white urban and suburban enclaves.

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.

Summary: CMS apparently took to heart concerns about the privatization of traditional Medicare with DCEs, pivoting to a new program ACO REACH focused on equity and disparities. Except that the new program is really no different than DCEs. Re-branding while continuing the march to corporate control of Medicare won’t cut it.

---

ACO REACH, CMS, February 2022

---

The Centers for Medicare & Medicaid Services (CMS) has redesigned the Global and Professional Direct Contracting Model (GPDC) Model in response to Administration priorities, including our commitment to advancing health equity, stakeholder feedback, and participant experience. CMS is renaming the model the ACO REACH Model to better align the name with the purpose of the model: to improve the quality of care for people with Medicare through better care coordination, reaching and connecting health care providers and beneficiaries, including those beneficiaries who are underserved, a priority of the Biden-Harris Administration.

---

Comparing GPDC to the ACO REACH Model, CMS, February 2022

---

A very detailed side-by-side table.

---

‘Band-Aid on a Tumor’: Critics Blast Biden Rebrand of Trump’s Medicare Privatization Scheme, February 25, 2022, by Jake Johnson

---

PNHP—which has implored the Department of Health and Human Services (HHS) to fully halt the program—outlined how the revamped pilot “perpetuates the dangerous flaws” of the Trump administration’s Direct Contracting experiment:

• Like the DC model, ACO REACH will pay middlemen a flat fee to “manage” seniors’ health, allowing them to keep 40% of what they don’t spend on care as profit and overhead.
• Traditional Medicare beneficiaries will still be automatically enrolled into ACO REACH entities without their full understanding or consent, and once enrolled cannot opt out of an ACO REACH entity unless they change primary care providers.
• Like DCEs, the ACO REACH program has virtually no limits on what type of company can participate; entities can be owned by commercial insurers, private equity investors, and other profit-seeking firms, including current Direct Contracting entities.
• The new program increases provider governance from 25% to 75% (with loopholes built into the application process), but ACO REACH entities are ultimately accountable to investors.

“Changing the name doesn’t change the fact that the Direct Contracting program is backdoor privatization of Medicare,” Alex Lawson, executive director of Social Security Works, said in a statement. “This dangerous experiment must be stopped before it further harms the health of vulnerable seniors, eats into the Medicare Trust Fund, and destroys traditional Medicare.”

---

Comment:

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

CMS responded to pressure from progressive organizations and lawmakers by offering a kinder, gentler version of DCEs – the ACO REACH model, focused on improving health care equity. Don’t believe it. Even in new clothing, the new DCE incarnation assures the same profits for corporations.

It’s all very similar to Medicare Advantage. See HJM’s earlier posts on DCEs: How Corporate Investors Deplete Medicare and CMS Direct Contracting Scheme Will Privatize Medicare.

Here are a few key problems with this re-branding:

Profiting from reduced care: As PNHP points out, both DCEs and REACH ACOs potentially retain 40% of medical care costs not incurred. But it’s actually worse than that – they retain 100% of the first 25% drop in spending. If they reduce care costs for a Medicare beneficiary from $10,000 to $7,500, they keep the entire savings of $2,500. (There’s a small “discount” to these savings for part of the program, to let CMS keep a tiny portion … and that’s being trimmed, to the benefit of corporate participants.)

Less focus on care quality: The “quality withhold” for failing to meet quality criteria is dropping from 5% to 2%. Less incentive to provide quality.

Risk Adjustment Manipulation: While there are some limits on upcoding of clinical severity, there are also exemptions and workarounds to permit the DCEs/ACOs to continue to game the system by bumping up apparent clinical severity and thus payments from CMS.

Ineffective Oversight: The REACH ACOs mandate provider and beneficiary roles in oversight, but with such loose definitions (eg of “provider”) and minimal participation (eg, one beneficiary on an oversight board) that control will remain with corporate investors and executives. Likewise, monitoring requirements (eg access to care) are vague and prone to manipulation and disregards given the history of CMS corporate favoritism.

Why, oh why, does CMS believe that shifting fee-for-service Traditional Medicare to something like Medicare Advantage will save money for Medicare and protect beneficiaries, when Medicare Advantage never has? (nor have ACOs)

Why, oh why, is CMS so influenced even in a Democratic administration by the perspectives of profit-making corporations?

Could it be the political donations and revolving door professional opportunities?

This is important. Read the Common Dreams article, and others that will follow. Track this issue.

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.