Saturday, July 20, 2019

Health Care Reform Articles - July 20, 2019

Column: In health care, the free-market model has failed
by Kenneth Dolkart - Valley News - July 15, 2019

“Medicare for All” is at the confluence of currents running through our nation. Consciousness is rising that we might enjoy the automatic, universal and high-quality care that is taken for granted in many nations. We trail the developed world in metrics of care like longevity, access, equity, infant and maternal mortality, and rates of death from causes otherwise amenable to care. All too often, ZIP code determines life expectancy.
The health industry sector outperforms the stock market, even as schools cannot afford insurance premiums for teachers.
Nurses and doctors watch countless people lose their health, since absent or inadequate medical coverage promotes belated attention to symptoms.
As some Americans enjoy wondrous medical advancements, others cannot afford the insulin they need. And a growing undertow of “diseases of despair,” such as suicide, alcoholism and opioid overdose, have taken their toll.
U.S. life expectancy has been declining the past three years, for the first time since 1918.
The consequences of the deregulation of medical insurance are obvious.
Costs of employee-sponsored family health insurance plans leaped ahead of inflation, from $5,791 in 1999 to $18,142 in 2016, according to the Kaiser Family Foundation. Middle-class incomes have been stagnant as wages are diverted to the “health dollar” and destined for insurance company profits and CEO salaries. Health insurance deductibles have risen 200 percent since 2008, along with other tactics that shift costs to the enrollee and discourage obtaining services.
The private managed care bureaucracy is geared to profit, and overall U.S. administrative costs are four times that of Canada and three times that of European nations, according to the Organization for Economic Cooperation and Development. Absent regulation allows unbridled and unjustified increases in drug and equipment prices. The cartel-like practice of “pay-for-delay” occurs regularly as drugmakers pay off generic companies to not produce cheaper — but otherwise identical — medication.
Apart from antitrust actions, the prices of medical products and services explode beyond what a reasonably functioning market would dictate.
It is evident that applying free-market consumer models to health care is as appropriate as applying rules of baseball to hockey.
Profits above patientsThe recent effects of the corporatization of medical “providers” are also clear.
The vanishing primary care doctor runs gauntlets to get tests reimbursed and hires staff solely to interact with insurers. Burnout from the ever-expanded clerical burdens of electronic medical records thins the ranks of doctors and nurses. The promise of electronic medical records was lost when it was hijacked for capturing billings, rather than clinical utility.
(Wouldn’t it be nice if the clinician could “ask Siri” to “find last pathology report” and “schedule blood count in two weeks,” or “analyze drug interactions”?)
Companies with a duty to put stock prices above patient interests cynically exploit the professional accountability of medical staff, as physician and author Danielle Ofri observed in a recent New York Times piece, “Is Exploiting Doctors the Business Plan?”)
Abuse of the public trust is certainly not unique to health care.
Industry-aligned Cabinet billionaires dismantle the federal oversight agencies they command. “Dark money” influence is unabated and oligarchs pull the levers of national legislation. Lobbyists for Big Oil mythologize climate change, big banks set the terms of their next failures and the National Rifle Association legislates a gun dystopia. So too, Big Pharma and health insurers profit from the legislation they draft.
Urban hospitals convert health dollar surplus into real estate investments, while rural hospitals collapse in the absence of coordinated support. The Justice Department tries to dismantle the Affordable Care Act scaffolding while millions of Americans are still on it.
Our multiple, episodically introduced, parallel public insurance systems still leave 30 million Americans uninsured.
Now there are numerous proposals to achieve universal coverage, reduce complexity and cut overall costs. Some “Medicare for All” plans propose incremental dissolution of profit-directed insurance bureaucracies with a single federal payer built upon Medicare. There is no “nationalization” of hospitals or doctors, as some critics charge.
“Medicare for Some” proposals, such as the “public option,” allow non-seniors to purchase Medicare and may be more politically palatable to those with employer-coverage, but they do not reduce complexity nor lower costs, and future recessions will eliminate such coverage for many.
Other well regulated and simplified hybrid systems can be envisioned. Still, any cost-effective system, “all-payer” or otherwise, requires transparent and uniform insurance industry practices, enforcement of existing regulations and the enabling of negotiation between tax-supported payers and drugmakers. So expect smoke, mirrors and twitters of fear, uncertainty and disinformation from the Partnership for America’s Health Care Future — a coalition of lobbying groups including America’s Health Insurance Plans, the American Medical Association, the Federation of American Hospitals and BigPharma — which is already hard at work.
We realize that the anonymous “dark money” financing of election efforts and the sanctioned bribing of Congress is incompatible with a representative democracy. Citizen efforts to create legislation for policies that have long had overwhelming support have been stymied by misinformation and the stoking of division, whether it be by the AMA or the NRA.
Still, the tide may be turning. Young people and an energized electorate are clamoring to “promote the general welfare, and secure the blessings of liberty” offered in the preamble to the Constitution. We will recognize such a democracy when, among other changes, this wealthy nation fulfills the moral imperative of assuring modern, universal and affordable health care to all Americans.
Kenneth Dolkart is a physician who lives in Grantham

Medicare for All and Private Insurance: It is like mixing oil and water

by James Kahn - - July 19,, 2019

At the recent Democratic debate, Lester Holt asked for a show of hands: Who would end the role of private insurance companies as part of health care reform? Four hands went up – Bernie Sanders, Bill de Blasio, Elizabeth Warren, and Kamala Harris. Other candidates argued for incremental expansions of Medicare within our current heavily private insurance system. John Delaney made a plea to “keep what’s working” – i.e., private insurance that people like. After the debate, Harris muddied the waters a bit, saying she misheard the question, and favored a role for private supplemental insurance. 
How do we make sense of all this? In this perspective, I unpack the idea of private insurance – considering benefit design, marketing, financial coverage, and profit status. I examine the potential role of private insurance in Medicare for All (M4A) or single payer health care. Preview: the role is minimal to none.
Let’s start with the current system. Private insurance, mainly employment-based, covers two-thirds of the population and one-third of health spending. It is typically fairly broad in the kinds of services covered, but with many limits and exclusions, and no standardization. Certain features, such as wellness care, are added to attract healthier enrollees. Marketing is intense. Financial coverage is highly variable, often with extensive cost-sharing (high deductibles, copays, and excluded services or providers). Most insurers are for-profit, and even among not-for-profits executive salaries are sky high. In these ways, private insurance echoes many features of other free market products.
Over the last decade, private insurance got a little better, then worse again. Obama’s Affordable Care Act (ACA) established standards for insurance to protect the policy holders, including required types of coverage (e.g., hospital and ambulatory), specified tiers of actuarial rates (percent of covered health care paid), community-based premiums (based on age and gender) rather than charging more for individuals with medical problems, maximums on out-of-pocket costs, and prohibition of egregious practices like “recission” (retroactively revoking insurance based on trivial errors in applying). The ACA also imposed an individual mandate, and set up insurance exchanges to facilitate that. Here’s the worse again part: The Trump administration has undone the mandate and created massive loopholes to foster insurance plans without protections for policyholders.
Private insurance has also permeated public programs. “Medicare Advantage” is the capitated (monthly set payment) alternative to traditional Medicare fee-for-service, which has been subsidized by Congress for years and still overcharges. Medigap policies cover costs not paid by Medicare. And the Medicaid program is now also largely capitated via private plans.
As you can see, private insurance is highly variable in the U.S.
Not so in other wealthy democracies. Outside the debates, some experts and pundits have proposed following the Swiss or German model of relying on private insurers instead of a government payer. This may leave the impression that their private insurance is like ours. In fact, they differ in nearly all important ways. First, the private insurers sell mainly a single, standardized benefit package. This broad benefit package assures excellent coverage. It also profoundly simplifies system administration – providers deal with a single set of rules and billing procedures. Second, financial coverage is much better: little or no deductible, low cost-sharing, and access to any provider, so no out-of-network charges. Third, marketing is very subdued. Finally, insurers are not-for-profit for these primary health plans. (Some ancillary insurance can be for-profit.)
So… is there a role for private insurance under M4A? 
The big answer is “no”. All M4A proposals, including the Sanders bill, have a single payer. This strategy is what confers the many gains of M4A. First, a single payer (the government) means simplicity for enrollees and providers, yielding a massive 10% overall savings via administrative streamlining. Having multiple insurers covering core services would undermine those gains. In addition, a single payer can effectively negotiate on prices, in particular with drug companies. Finally, and importantly, having private insurance would undermine equity and a shared commitment to the public payment system. Imagine someone making $1 million per year and because of progressive tax-based financing is paying the costs of five people on the public plan. People in that position may feel it’s justified to reduce the public system generosity by 20% to pay for his insurance plan. Or that wealthy person may insist on tax subsidies for private insurance premiums, again stealing money from the public system. We’d be exacerbating inequality.
OK, so no major private insurance role within single payer. Is there any role?
  • What about emulating the Swiss system? Perhaps…but can we really get there, given our corporate culture? One product, not-for-profit? What companies would be interested?
  • What about insuring gaps in coverage? Good question. M4A proposals don’t have major gaps in coverage, except sometimes long term care. Private insurance might have a focused role there, but nothing as large as Medigap today. In my view this would be suboptimal, but it’s a reasonable discussion.
  • What about Kaiser and other HMO models? Some M4A proposals allow for capitated care systems. Personally I think that’s a good idea. But it wouldn’t be insurance, it would be a care system.
  • What about supplemental coverage for low-value/non-core medical services, such as private hospital rooms or alternative care models? As long as it’s not totally discretionary (like most cosmetic surgery), could be.
  • Could private insurers handle the billing process? There could be private vendors for these services, and current insurers have some expertise in this area. But it’s not really private insurance.
  • What about for individuals who want care from providers who choose not to participate in M4A, e.g., concierge medicine? That will be out-of-pocket, not insurance. See above for all the problems with allowing private insurance for core services.
  • What do we say to people who like their health insurance? We ask them, is it your insurance you like, or excellent access to providers and coverage of care? Because under single payer both will improve – access to any provider, and low or no cost-sharing.
Ultimately, in my view, private insurance cannot have a central role in M4A, because it would undercut what’s so powerful about a single payer. But perhaps it can have a focused role.
James G. Kahn MD MPH is Emeritus Professor of health policy at the University of California San Francisco.

Send Me Back to the Country I Came From

by Timothy Egan - NYT - July 19, 2019

He’s right, this angry old man in melting bronzer shouting in the July heat: Those of us who don’t like what’s going on in this country should get the hell out. “Go back,” as he said, to the “crime-infested places from which they came.” A fine idea.
For me, as with more than 30 million other Americans with my hyphenate, that’s tiny Ireland, the country once so infested with crime, famine, disease and assorted horrors of foreignness that its British overlords said a merciful God was doing a favor by killing off the starving masses.
So back I went to have a look. This, mind you, was just before President Trump’s suggestion to his fellow citizens to get out. And also, generations after someone on my father’s side made the choice to flee for life itself, rather than fall into the cold Irish ground through the bottom of a reusable coffin.
What I found on that island where typhus once took entire families as they shivered on floors of mud, where, by one medical estimate, 50 percent of the children in Dublin once died before their first birthday, is now a land of universal health care.
Health care for all residents: It’s still a surprise to someone from a nation where the number of uninsured Americans has gone up by seven million under Trump. I had left a place where nearly one in seven people are left to fend for themselves when sick, to a fully covered country, the norm in most of the industrialized world.
What I found in that place where barefooted, Gaelic-speaking hordes once could not read an English sign are colleges nearly free to its citizens — good colleges, at that. Imagine, a family not having to bankrupt itself to help a child off to a better life.
What I found is a republic where nearly one in eight people were born abroad, nearly as high a percentage as the foreign-born population of the United States. The prime minister, Leo Varadkar, is himself a son of an Indian immigrant. His father was born in Mumbai, while his mother hails from County Waterford, the home also of my mother’s distant family.
That 19th-century hellhole has become a 21st-century heaven. The Irish have become us — what we wanted and aspired to. They are living our national narrative, a country open to those fleeing oppressors and lack of opportunity. Its prime minister would never gloat over a “send her back” chant at a hatefest directed at new members of the republic.
Back home in America, the unimaginable is the new norm: a fully blossoming fascism. We’re stuck in a hideous loop of hate. But it‘s also an idiocy loop.
Why are we arguing about something any second grader has already settled after looking around the classroom and realizing that nearly every other child is a descendant of someone from a foreign land?
Read the resolution the House of Representatives passed on Tuesday, citing Ronald Reagan, John F. Kennedy and Benjamin Franklin, and quoting Franklin Roosevelt’s call to “remember always, that all of us, and you and I especially, are descended from immigrants and revolutionists.” It’s the kind of immigrants-make-a-nation-stronger boilerplate that would normally pass the House with unanimous consent, but it drew only four Republican votes.
This is how low Trump has taken us. We are a debased nation fighting over the scraps of our former principles. Should someone offer a resolution saluting the “purple mountain majesties” of the United States, every Republican would vote against it if Trump tweeted against a color that is not orange. Senator Mitch McConnell, whose immigrant wife is indirectly a target of this sludge, would say, as he did about the “send-her-back chants,” that the president is “on to something.”
I’m against the dismissal of others with the pre-emptive pejorative of “white privilege.” It closes minds and ends conversations. But this is one case where white privilege applies. For Trump’s tweet wasn’t aimed at me. Nor was it directed at his vice president, the cipher and coward Mike Pence, himself an Irish-American.
Trump’s hate blast was directed solely at people of color.
His tweet was the textbook definition of racism. And I should add in the interest of full transparency, I disagree with much of the policy initiatives of the four left-wing congresswomen targeted by Trump. It was wrong and incorrect for them to make Nancy Pelosi’s disagreement with them about race. That episode was another textbook illustration of why the far left has trouble winning a majority.
But let’s leave that discussion for another day. Back in the country from which I came, the Irish appear genuinely perplexed at this American vomiting of principle. Writing in “Irish Times,” Oliver Sears, a British-born resident of Ireland and son of a Polish holocaust survivor, wondered how any immigrant could ever vote for Trump.
I heard a similar thing when I went back: How could Irish-Americans vote for this awful man without becoming traitors to their heritage? For this Ireland has become what America used to be. If only America could be more like this Ireland. 

Health Insurers Make It Easy for Scammers to Steal Millions. Who Pays? You.

by Marshall Allen - Pro Publica - VOX - July 19, 2019   

Ever since her 14-year marriage imploded in financial chaos and a protective order, Amy Lankford had kept a wary eye on her ex, David Williams.
Williams, then 51, with the beefy body of a former wrestler gone slightly to seed, was always working the angles, looking for shortcuts to success and mostly stumbling. During their marriage, Lankford had been forced to work overtime as a physical therapist when his personal training business couldn’t pay his share of the bills.
So, when Williams gave their three kids iPad Minis for Christmas in 2013, she was immediately suspicious. Where did he get that kind of money? Then one day on her son’s iPad, she noticed numbers next to the green iMessage icon indicating that new text messages were waiting. She clicked.
What she saw next made her heart pound. Somehow the iPad had become linked to her ex-husband’s personal Apple device and the messages were for him.
Most of the texts were from people setting up workouts through his personal training business, Get Fit With Dave, which he ran out of his home in Mansfield, Texas, a suburb of Fort Worth. But, oddly, they were also providing their birthdates and the group number of their health insurance plans. The people had health benefits administered by industry giants, including Aetna, Cigna and UnitedHealthcare. They were pleased to hear their health plans would now pay for their fitness workouts.
Lankford’s mind raced as she scrolled through the messages. It appeared her ex-husband was getting insurance companies to pay for his personal training services. But how could that be possible? Insurance companies pay for care that’s medically necessary, not sessions of dumbbell curls and lunges.
Insurance companies also only pay for care provided by licensed medical providers, like doctors or nurses. Williams called himself “Dr. Dave” because he had a Ph.D. in kinesiology. But he didn’t have a medical license. He wasn’t qualified to bill insurance companies. But, Lankford could see, he was doing it anyway.
As Lankford would learn, “Dr. Dave” had wrongfully obtained, with breathtaking ease, federal identification numbers that allowed him to fraudulently bill insurers as a physician for services to about 1,000 people. Then he battered the system with the bluntest of ploys: submit a deluge of out-of-network claims, confident that insurers would blindly approve a healthy percentage of them. Then, if the insurers did object, he gambled that they had scant appetite for a fight.
By the time the authorities stopped Williams, three years had passed since Lankford had discovered the text messages. In total, records show, he ran the scheme for more than four years, fraudulently billing several of the nation’s top insurance companies — United, Aetna and Cigna — for $25 million and reaping about $4 million in cash.
In response to inquiries, Williams sent a brief handwritten letter. He didn’t deny billing the insurers and defended his work, calling it an “unprecedented and beneficial opportunity to help many people.”
“My objective was to create a system of preventative medicine,” he wrote. Because of his work, “hundreds of patients” got off their prescription medication and avoided surgery.
There are a host of reasons health care costs are out-of-control and routinely top American’s list of financial worries, from unnecessary treatment and high prices to waste and fraud. Most people assume their insurance companies are tightly controlling their health care dollars. Insurers themselves boast of this on their websites.
In 2017, private insurance spending hit $1.2 trillion, according to the federal government, yet no one tracks how much is lost to fraud. Some investigators and health care experts estimate that fraud eats up 10% of all health care spending, and they know schemes abound.
Williams’ case highlights an unsettling reality about the nation’s health insurance system: It is surprisingly easy for fraudsters to gain entry, and it is shockingly difficult to convince insurance companies to stop them.
Williams’ spree also lays bare the financial incentives that drive the system: Rising health care costs boost insurers’ profits. Policing criminals eats away at them. Ultimately, losses are passed on to their clients through higher premiums and out-of-pocket fees or reduced coverage.
Insurance companies “are more focused on their bottom line than ferreting out bad actors,” said Michael Elliott, former lead attorney for the Medicare Fraud Strike Force in North Texas.
As Lankford looked at the iPad that day, she knew something else that made Williams’ romp through the health care system all the more surprising. The personal trainer had already done jail time for a similar crime, and Lankford’s father had uncovered the scheme.

Scanning her ex-husband’s texts, Lankford, then 47, knew just who to call. During the rocky end of her marriage, her dad had become the family watchdog. Jim Pratte has an MBA in finance and retired after a career selling computer hardware, but even the mention of Williams flushed his face red and ratcheted up his Texas twang. His former-son-in law is the reason he underwent firearms training.
Lankford lived a few minutes away from her parents in Mansfield. She brought her dad the iPad and they pored over message after message in which Williams assured clients that their insurance would cover their workouts at no cost to them.
Lankford and Pratte, then 68, were stunned at Williams’ audacity. They were sure the companies would quickly crackdown on what appeared to be a fraudulent scheme.
Especially because Williams had a criminal record.
In early 2006, while Williams and Lankford were going through their divorce, the family computer started freezing up. Lankford asked her dad to help her recover a document. Scrolling through the hard drive, Pratte came upon a folder named “Invoices,” and he suspected it had something to do with Williams.
His soon to be ex-son-in-law had had a promising start. He’d wrestled and earned bachelor’s and master’s degrees at Boise State University, and a Ph.D. at Texas A&M University, before landing a well-paying job as a community college professor in Arlington. But the glow faded when the school suddenly fired him for reasons hidden by a confidential settlement and by Williams himself, who refused to reveal them even to his wife.
Out of a job, Williams had hustled investments from their friends to convert an old Winn-Dixie grocery store into a health club called “Doc’s Gym.” The deal fell apart and everyone lost their money. The failure was written up in the local newspaper under the headline: “What’s up with Doc’s?”
Inside the “Invoices” folder, Pratte found about a dozen bills that appeared to be from a Fort Worth nonprofit organization where his daughter and Williams took their son Jake for autism treatment. As Pratte suspected, the invoices turned out to be fake. Williams had pretended to take Jake for therapy, then created the false bills so he could pocket a cash “reimbursement” from a county agency.
In November 2008, Williams pleaded guilty in Tarrant County District Court to felony theft. He was sentenced to 18 months in jail and was released on bail while he appealed.
Things took an even darker turn about two years later when Williams and Lankford’s 11-year-old son showed up to school with bruising on his face. Investigators determined that Williams had hit the boy in the face about 20 times. Williams pleaded guilty to causing bodily injury to a child, a felony, which, coupled with the bail violation, landed him in jail for about two years.
The time behind bars didn’t go to waste. Williams revised the business plan for Get Fit With Dave, concluding he needed to get access to health insurance.
Williams detailed his plans in letters to Steve Cosio, a tech-savvy friend who ran the Get Fit With Dave website in exchange for personal training sessions. Cosio, whose name later popped up on Lankford’s son’s iPad, kept the letters in their original envelopes and shared them with ProPublica. He said he never suspected Williams was doing anything illegal.
In his letters, Williams said that when he got out, instead of training clients himself, he would recruit clients and other trainers to run the sessions. “It has the potential for increased revenue.”
He asked Cosio to remove the term “personal training” from his website in another letter, adding “95 percent of my clients are paid for by insurance, which does not cover ‘personal training,’ I have to bill it as ‘therapeutic exercise.’ It is the same thing, but I have to play the insurance game … Insurance pays twice as much as cash pay so I have to go after that market.”
Williams downplayed his child abuse conviction — “I can honestly say that I am the only one in here for spanking their child” — and included a dig at his ex-father-in-law, Pratte: “an evil, evil man. He is the reason for my new accommodations.”
Williams told Cosio he needed to raise a quick $30,000 to pay an attorney to get him access to his children. “I will need to get a bunch of clients in a hurry.”

To set his plan in motion, Williams needed what is essentially the key that unlocks access to health care dollars: a National Provider Identifier, or NPI number.
The ID number is little known outside the medical community but getting one through the federal government’s Medicare program is a rite of passage for medical professionals and organizations. Without it, they can’t bill insurers for their services.
One would think obtaining an NPI, with its stamp of legitimacy, would entail at least some basic vetting. But Williams discovered and exploited an astonishing loophole: Medicare doesn’t check NPI applications for accuracy — a process that should take mere minutes or, if automated, a millisecond. Instead, as one federal prosecutor later noted in court, Medicare “relies on the honesty of applicants.”
Records show Williams first applied for an NPI under his own name as far back as 2008. But it wasn’t until 2014 that Williams began to ramp up his scheme, even though now he wasn’t just unlicensed, he was a two-time felon. He got a second NPI under the company name, Kinesiology Specialists. The following year, he picked up another under Mansfield Therapy Associates. In 2016, he obtained at least 11 more, often for entities he created in the areas where he found fitness clients: Dallas, Nevada, North Texas and more. By 2017, he had 20 NPIs, each allowing him a new stream of billings.
For every NPI application, Williams also obtained a new employer identification number, which is used for tax purposes. But he never hid who he was, using his real name, address, phone number and email address on the applications. He added the title “Dr.” and listed his credentials as “PhD.” Under medical specialty he often indicated he was a “sports medicine” doctor and provided a license number, even though he wasn’t a physician and didn’t have a medical license.
Medicare officials declined to be interviewed about Williams. But in a statement, they acknowledged that the agency doesn’t verify whether an NPI applicant is a medical provider or has a criminal history. The agency claims it would need “explicit authority” from the Department of Health and Human Services to do so — and currently doesn’t have it. Regulations, and potentially the law, would need to be revised to allow the agency to vet the applications, the statement said.
Medicare does verify the credentials of physicians and other medical providers who want to bill the agency for their Medicare patients.
To those charged with rooting out fraudsters, the current regulations seem like an invitation to plunder.
“Medicare has to make sure that the individuals who apply for NPIs are licensed physicians — it’s that simple,” said Elliott, the former prosecutor who ran about 100 health care fraud investigations.
Elliott, who now does white-collar criminal defense, said he knows of two other cases currently under federal investigation in which non-licensed clinic administrators lied to obtain NPI numbers, then used patients’ information to file false claims worth millions.
Medicare warns NPI applicants that submitting false information could lead to a $250,000 fine and five years in prison. But since Medicare started issuing NPIs in 2006, officials said they could not identify anyone who had been sanctioned.
So, for those bent on fraud, the first step is easy; the online approval for an NPI takes just minutes.

Williams got out of jail in November 2012 and launched an aggressive expansion with an irresistible pitch: Time to get those private personal training sessions you thought you couldn’t afford!
“Now accepting most health insurance plans,” his Get Fit With Dave website announced. He added a drop-down menu to his site, allowing potential clients to select their health insurance provider: Aetna. Blue Cross Blue Shield. United.
He began building a team, soliciting trainers from the strength and conditioning department at Texas Christian University. He met with new recruits at local fast food joints or coffee shops to set them up. To the trainers, the business appeared legit: They even signed tax forms. Before long, Williams’ network stretched throughout Texas and into Colorado, Idaho and Nevada.
One Fort Worth trainer recalled meeting Williams through one of his clients, a Southwest Airlines flight attendant. Williams, he said, seemed like a real doctor, and it wasn’t hard to imagine an insurer’s wellness program covering fitness. Plus, it was good money — about $50 an hour and Williams paid him for multiple clients at once if he did boot camps, said the trainer, who asked that his name not be used so he wouldn’t be tarnished by his association with Williams. Williams, he said, even gave him an iPad, with “Kinesiology Specialists” etched on the back, to submit bills and paid him via direct deposit.
Clients came to Williams through his business cards, his website and word-of-mouth. Williams, records show, quickly verified if their insurance companies would cover his fees — although he didn’t tell clients that those fees would be billed as medical services, not personal training. To ensure the clients paid nothing, he waived their annual deductibles — the portion patients pay each year before insurance kicks in. Authorities said Williams banked on being able to file enough claims to quickly blow through their deductibles so he could get paid.
Meredith Glavin, a flight attendant with Southwest, told the authorities she got in touch with Williams after her co-workers said insurance was covering their workouts. After providing her name, address and insurance information on the Get Fit With Dave website, Williams emailed back with the good news: “Everything checks out with your insurance. My services will be covered at no cost to you.”
During a follow-up phone call, Glavin said, they discussed her fitness and weight loss goals and then Williams connected her with a trainer. The workouts were typical fitness exercises, she said, not treatment for a medical condition. But insurance claims show Williams billed the sessions as highly complex $300 examinations to treat “lumbago and sciatica,” a condition in which nerve pain radiates from the lower back into the legs.
He used his favorite billing code — 99215 — to bill Glavin’s insurer, United, the claims show. The code is supposed to be used less often because it requires a comprehensive examination and sophisticated medical decision-making, warranting higher reimbursement. In all, Williams used the code to bill United for more than $20.5 million — without apparently triggering any red flags at the insurer. For that code alone, the insurance giant rewarded him with $2.5 million in payments.
Eventually, Get Fit With Dave expanded to about a dozen trainers and around 1,000 patients, said a source familiar with the case. And, court records show, the checks from insurance companies, some over $100,000, kept rolling in.
Williams bought a couple of pick-up trucks, a new Harley Davidson motorcycle and a fancy house. But greed didn’t seem his only motivation. “I made $50K last week,” he wrote in a December 2014 text to a friend. “Seriously it means nothing. It is not about the money. I have had a lot taken away from me, and maybe I am trying to prove something ... Maybe it is my way of giving the finger to everyone???”

A few miles away, his former father-in-law watched Williams’ illegal business blossom with growing outrage. Pratte kept his grandson’s iPad on his desk, near his computer, and checked it every day. The texts appeared boring, even routine, but Pratte knew they were evidence of ongoing fraud.
“I have another flight attendant friend who is interested in signing up as well,” a new client texted to Williams.
“Tell him to show up with his insurance card,” Williams replied.
To Pratte, the text messages were a “gold mine.” This is the stuff that will really nail his rear end, he recalled thinking as he read the messages. He couldn’t wait to share his findings with the insurers. How often do they get cases wrapped up in a bow?
But when he and Lankford began contacting insurers, they were soon bewildered. When Pratte told Aetna that he wanted to report a case of fraud, he said the customer service representative asked for his member number, then told him non-members couldn’t report criminal activity. Lankford, who happened to be covered by Aetna, made the complaint, but they say they never heard back.
An Aetna spokesman told ProPublica that the insurer could find no record of Pratte’s call but said the company’s fraud hotline takes tips from anyone, even anonymous callers.
Lankford sent an email to Cigna’s special investigations unit in January 2015 “regarding one of your providers that concerns me.” She provided Williams’ company name, address, cellphone number, Social Security number and more, and she described his scheme. “He has no medical license or credentials,” she wrote. “He was in prison for felony theft.”
A supervisory investigator called to ask for the names of personal trainers, which Lankford provided. But, again, there was silence.
Pratte could see many of the clients worked for Southwest and had their benefits administered by United. He jotted down the name, address, phone number, birthdate and member identification number of the potential clients on a yellow legal pad — all the information the insurer and Southwest would need to investigate the fraud. This is so easy, Pratte recalled thinking as he wrote down the details, all they have to do is cross-reference this.
Because Southwest self-funds its benefits, the company was on the hook for the bills, which would eventually total about $2.1 million according to a source familiar with the case. It paid United to administer the company’s plan and ensure the claims it covered were legitimate. Pratte said he called the airline in the fall of 2015 and spoke to someone in the human resources department who said they would pass the information to the right people. “That was the last I heard,” he said. Southwest declined to comment for this story. It still pays United to administer its benefits.
Pratte started calling United in the fall of 2014 and spoke to a fraud investigator who took the information with interest, he said. But within a couple of weeks he was told she moved to a different position. Pratte continued calling United over the following two years, making about a dozen calls in total, he said. “He is not a doctor,” Pratte told whoever picked up the phone. “So, I don’t see how he can be filing claims.”
In early 2015, Lankford emailed additional information to the investigator. The investigator wrote back, thanking Lankford and saying she forwarded the details to the people who research licenses. “They will investigate further,” she said in the email.
Meanwhile, the text messages showed Williams continuing to sign up — and bill for — United members.
Frustrated, Pratte made one final call to United in 2016, but he was told the case was closed. United said he’d have to call the Texas Department of Insurance for any additional details. Pratte had already filed a complaint with the regulator but reached out again. The department told him that because he hadn’t personally been defrauded, it would not be able to act on his complaint.
To Pratte, it appeared he had struck out with Aetna, United, Southwest and the Texas Department of Insurance. “I was trying to get as many people as possible to look into it as I could,” Pratte said recently. “I don’t know if that tells me they are incompetent. Or they don’t care. Or they’re too busy.”
A case summary, prepared by the Texas Department of Insurance, shows it first learned of the Williams case in January 2015 but lacked staff to investigate. A spokesman said the regulator later received Pratte’s complaint but didn’t pursue it after learning that United had already investigated and closed its case.
Meanwhile, some Get Fit With Dave clients had begun noticing odd claims on their insurance statements.
Nanette Bishop had heard about Williams when a fellow Southwest flight attendant handed her the trainer’s business card and said, “You’ve got to meet Dr. Dave.” (Bishop said the Southwest legal department advised her not to speak with ProPublica. Details about her interaction with Williams come from court records.)
Bishop said she started strong with the workouts but “fizzled” quickly. Her daughter, who was also on her plan and signed up for workouts, only did a couple sessions. Bishop said she had a hard time staying consistent because she was traveling a lot — for much of October 2014 she was in Germany. Later, she noticed in her insurance records that Williams had been paid for dozens of sessions over many months, even during the time she’d been abroad.
Bishop texted Williams in January 2015 to tell him he needed to refund all the money. “I never worked out four [times] a week and [my daughter] quit the first week of September,” she wrote. Bishop also called United and Southwest Airlines to report the overbilling.
About a month later, Williams received a letter from a subsidiary of United ordering a review Bishop’s medical records.
Another client texted Williams with concerns that her United insurance plan had been billed for 18 workouts in December 2015. That couldn’t be accurate, the woman wrote. “I had to take December off due to my work schedule and family in town,” she wrote. “I understand that people need to be paid but this seems excessive.”

While Pratte, Lankford and some of Williams’ clients repeatedly flagged bogus bills, the mammoth health insurers reacted with sloth-like urgency to the warnings. Their correspondence shows an almost palpable disinterest in taking decisive action — even while acknowledging Williams was fraudulently billing them.
Cigna appears to have been the quickest to intervene. In January 2015, Cigna sent Williams a letter, noting that he wasn’t a licensed medical provider and had misrepresented the services he provided. The insurer said he needed to pay back $175,528 and would not be allowed to continue billing.
“I just got a $175K bill in the mail,” Williams texted to a friend. “Cigna insurance has been overpaying me for the past 18 months and they want it back. I knew that they were reimbursing at too high of a rate so I can’t really complain.”
By then Williams had more than one National Provider Identifier, so he just switched numbers and kept billing Cigna. More than a year later, in May 2016, Cigna sent another letter, saying he now owed $310,309 for inappropriate payments. In total, the company paid him more than $323,000. Williams never gave any of it back. Cigna declined to comment about the Williams case.
Aetna wrote Williams in January 2015 to say it had reviewed his claims and found he wasn’t licensed, resulting in an overpayment of $337,933. The letter said there appeared to be “abusive billing” that gave “rise to a reasonable suspicion of fraud.” But the insurer also gave him a month to provide documentation to dispute the assessment. When Williams hadn’t responded in three months, an Aetna investigator wrote to Williams’ attorney, saying, “We are willing to discuss an amicable resolution of this matter,” and gave him two more weeks to respond.
That August, an Aetna attorney sent Williams’ attorney another letter, noting that Williams had submitted “fraudulent claims” and had continued to submit bills “even after his billing misconduct was identified.”
In January 2016 — a year after Aetna first contacted him — Williams agreed to a settlement that required him to refund the company $240,000 “without admission of fault or liability by either party.”
But that didn’t stop, or even appear to slow, Williams. Not only did he renege on that promise, he picked one of his other NPI numbers and continued to file claims resulting in another $300,000 in payments from Aetna. In total, Aetna paid Williams more than $608,000.
In emails, Ethan Slavin, a company spokesman, didn’t explain why Aetna settled with Williams instead of pursuing criminal prosecution. He blamed the insurer’s slow response on the lengthy settlement process and Williams’ tactic of billing under different organizations and tax identification numbers. Williams did repay some of the money before defaulting, Slavin said.
United, one of the largest companies in the country, paid out the most to Williams. The insurer brought in $226 billion last year and has a subsidiary, Optum, devoted to digging out fraud, even for other insurers. But that prowess is not reflected in its dealings with Williams.
In September 2015, United wrote to Williams, noting his lack of a license and the resulting wrongful payments, totaling $636,637. But then the insurer added a baffling condition: If Williams didn’t respond, United would pay itself back out of his “future payments.” So while demanding repayment because Williams was not a doctor, the company warned it would dock future claims he would be making as a doctor.
Williams responded a month later, noting that he had a Ph.D. in kinesiology and did rehab, so he met the qualifications of a sports medicine doctor.
United responded in November 2015 with the same argument: he wasn’t licensed and thus needed to repay the money, again warning that if he didn’t, United would “initiate repayment by offsetting future payments.”
Williams took United up on its offer. “Please offset future payments until the requested refund amount is met,” he responded.
Then Williams turned to another NPI number, records show, and continued submitting claims to United.
In January 2016, Williams agreed to settle with United and repay $630,000 in monthly installments of $10,000. Inexplicably, the agreement refers to Williams as “a provider of medical services or products licensed as appropriate under the laws of the state of TX” and notes that the settlement doesn’t terminate his continued participation in United’s programs.
In 2016, Williams obtained a new batch of NPI numbers from Medicare. As usual, he used his real name, address and credentials on the applications. The additional numbers allowed him to continue to make claims to United.
In November 2016, United investigators caught Williams again — twice. They sent two letters accusing him of filing 820 claims between May 2016 and August 2016 and demanded repayment. Again, almost inconceivably, the company threatened to cover his debt with “future payments.”
In December 2016, United notified Williams he had only repaid $90,000 of the initial $630,000 he owed and was in default. The following month, United told him he had to pay the remaining $540,000 within 20 days or he could face legal action. Williams replied, saying he wanted to renegotiate the settlement, but the insurer declined. Late that month, United said its inappropriate payments to Williams had ballooned to more than $2.3 million.
A United spokeswoman said it was difficult to stop Williams because he used variations on his name and different organizations to perpetrate the fraud. “He did everything he could not to get caught,” Maria Gordon-Shydlo said.
She acknowledged getting the complaints from Lankford and Pratte, as well as United members, but defended the response of the company, saying it had eventually referred Williams to law enforcement.
The insurer is continuing “to improve our processes and enhance our systems so we can catch these schemes on the front-end,” she said, “before a claim is paid and to recoup dollars that were paid as a result of provider misconduct.”
In all, United paid Williams more than $3.2 million — most of it after the insurer had caught him in the act.
But in reality, the losses weren’t all United’s. Most of the fraud was funded by its client, Southwest.

Many health care experts and fraud investigators said they weren’t surprised to hear that insurers were slow to stop even such an outlandish case of fraud.
“It’s just not worth it to them,” said Dr. Eric Bricker, an internist who spent years running a company that advised employers who self-funded their insurance.
For insurance behemoths pulling in billions, or hundreds of billions, in revenue, fraud that sucks away mere millions is not even a rounding error, he said.
And perhaps counterintuitively, insurance companies are loath to offend physicians and hospitals in their all-important networks — even those accused of wrongdoing, many experts have said. They attract new clients by providing access to their networks.
This ambivalence toward fraud, Bricker and others said, is no secret. Scammers like Williams are “emblematic of gazillions of people doing variants of the same thing,” Bricker said. Insurers embolden them by using a catch-and-release approach to fraud, in which the insurers identify criminals, then let them go.
Joe Christensen has pursued fraud for both government and commercial insurers, serving as a director in Aetna’s Special Investigations Unit, a team of more than 100 people ferreting out fraud, from 2013 to 2018 and as the director of Utah’s insurance fraud division for 13 years. Fraud in government programs, like Medicare and Medicaid, gets more publicity, he said, and has dedicated arms of agencies pursuing fraudsters. But the losses may be even greater in the commercial market because the dollar levels are higher, he said.
Some commercial insurers take a passive approach, Christensen said, in part because it’s expensive to press a fraud case. At Aetna, he said, investigators would identify cases of apparent fraud, but it was up to the executives and legal team to decide how to handle them. Taking fraudsters to civil or criminal court requires resources, so the company often settled for trying to get repaid through settlements or blocking a suspect provider from billing, he said.
Christensen said while he was at Aetna, investigators almost never sought to partner with law enforcement agencies to pursue criminal cases. Last spring, he became the SIU director for a Southern California-based Medicaid plan called L.A. Care Health Plan, where he was allowed to take a proactive approach. In just about a year, he said, his much smaller team began 37 criminal investigations with law enforcement agencies. The cases are in different stages, but so far there have been seven arrests, four search warrants and one conviction. Christensen recently took a job with an insurer in Utah, where his family lives, so he could be closer to them.
ProPublica asked Aetna how many criminal cases it had pursued in 2017 and 2018. A company official said the question could not be answered because it does not track such cases.

In the spring of 2017, more than four years after Williams first began billing insurers, one of them, United, finally brought him to the attention of the FBI’s heath care fraud squad.
One May day, agents from the FBI and the newly engaged Texas Department of Insurance knocked on the door of Williams’ sprawling six-bedroom home — a spread he’d boasted to one trainer that he’d purchased with cash. Williams didn’t invite them in. He refused to answer questions, claiming his attorney had dealt with the questionable billings.
Undaunted, just days later, Williams used a freshly minted NPI number to send another bill to United. The last known claim he submitted was on June 3, 2017, according to a source familiar with the investigation.
That October, Williams’ long run came to an end when he was arrested by the FBI.
The following May, Williams’ trial began in the United States District Court for the Northern District of Texas. The prosecution didn’t have to make a complex argument. Williams had billed for non-medically necessary services and wasn’t a medical provider — a “slam dunk case” said the agent on the case.
But the testimony served as a cheat sheet for how to defraud the health insurance industry and mostly get away with it.
Without irony, the prosecutor, P.J. Meitl, argued that Williams had preyed on a health insurance system that relies “on trust, relies on honesty” when it pays claims.
He called fraud investigators from Aetna, Cigna and United, who testified that their companies auto-pay millions of claims a year. It’s not cost effective to check them, they said. “Aetna relies on the honesty of the person submitting the claim verifying that it’s true,” testified Kathy Richer, a supervisor in Aetna’s Special Investigations Unit.
In a similar manner, Medicare trusts that people who apply for NPI numbers are actually medical providers, Meitl told the jury. Medicare “does not investigate or verify whether an individual is actually a health care provider before issuing an NPI number.”
Williams’ attorney, Wes Ball, argued that the case was the sign of a “broken” health care system and blamed insurers for making a financial decision not to review Williams’ claims before paying them. United failed to protect Southwest’s money, Ball said, and “might be a vendor you might not want to hire.”
As for the NPI numbers, anyone could have checked Williams’ credentials, he said.
The jury wasn’t convinced, convicting Williams of four counts of health care fraud.
The judge sentenced him to a little more than nine years in federal prison and ordered him to pay $3.9 million in restitution to United, Aetna and Cigna.

Insurers promote themselves as guardians of health care dollars. United says on its website it wants to “help employers manage” medical expenses, resulting in “lower costs.” Aetna promises employers “affordability.” Cigna promises “increased savings.”
But private health insurers allow so much fraud that prosecutors use an idiom to describe the rare person who gets caught: “Pigs get fat, hogs get slaughtered.”
“Pigs” can steal millions, if they bill just enough to avoid notice. But if they get greedy and bill too many millions, they “become a data outlier,” said Elliott, the former fraud task force prosecutor. “You get slaughtered.”
Williams took years to reach hog status.
Part of the problem, experts say, is that health care fraud is often misunderstood as shafting greedy insurers — not the folks paying for health insurance. Ultimately, insurers don’t bear the cost. For their self-funded clients, like Southwest, they merely process the claims. For their traditionally insured clients, they can recover any losses by increasing deductibles and premiums and decreasing coverage.
Williams appears to have duped more than insurers. His twin brother, Dan Williams, recently retired as the assistant special agent in charge of the Dallas field office for criminal investigation for the Internal Revenue Service. He spent 27 years ferreting out fraud, and he gets the irony. “You’re not the first person to point that out,” he said.
Dan Williams said his brother’s sudden riches from the training business piqued his investigative instincts, but he “trusted” his brother when “he told me he was authorized to bill insurance companies.”
In his letter to ProPublica, Williams did not address the issues in the case or even acknowledge that any of his activities were wrong. Instead, he blamed his former wife.
“It grieves me that the consequences of a bitter and hurtful divorce have resulted in the ending of this unprecedented and beneficial opportunity to help many people,” he wrote.
Lankford and Pratte are proud of their part in ending his scheme, if still baffled that they had to play such a central role in uncovering it.
If it hadn’t been for the iPad messages, “I have to believe he would still be billing insurance companies from a Caribbean island,” Pratte said.
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Sanders and Biden Fight Over Health Care, and It’s Personal

By Sydney Ember and Katie Glueck - NYT - July 18, 2019

WASHINGTON — Senator Bernie Sanders does not understand Joseph R. Biden Jr.’s position on health care. To Mr. Sanders, the health care system is broken, and the only way to fix it is to replace it with his signature policy plan known as Medicare for All.
“I am disappointed, I have to say, in Joe, who is a friend of mine, really distorting what Medicare for All is about,” Mr. Sanders said in an interview hours before he delivered a speech on Wednesday defending his health care proposal. “And unfortunately, he is sounding like Donald Trump. He is sounding like the health care industry in that regard.”
To Mr. Biden, the current Democratic front-runner, Medicare for All is a costly and complex proposal that means eliminating private health insurance — and scrapping the Affordable Care Act.
“I knew the Republicans would do everything in their power to repeal Obamacare,” he said in a video this week as he rolled out his own health care proposal. “They still are. But I’m surprised that so many Democrats are running on getting rid of it.”
After months of warily watching each other from afar, Mr. Sanders and Mr. Biden, two Democratic septuagenarian contenders for president, have taken aim at each other on the fraught and critical battleground of American health care policy.
Mr. Sanders in particular has escalated the attacks in recent days. His campaign called Mr. Biden’s health care plan “Bidencare” and even released a video that accuses him of “lying” about Medicare for All. But Mr. Biden, too, has been a more-than-willing participant, openly criticizing Medicare for All on multiple campaign swings over the last week.
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Their sparring reflects strategic political calculations. For Mr. Biden, who appears increasingly willing to draw contrasts with his Democratic rivals after a rocky first presidential debate, health care provides a way to highlight distinctions between himself and several opponents who support Medicare for All, including Mr. Sanders and Senators Kamala Harris and Elizabeth Warren.
For Mr. Sanders, outraised by several rivals including Ms. Warren and falling in some polls, Medicare for All — which he has preached for decades — offers a possible path back to the center of the national political conversation.
But there is more to their jousting than just normal campaign maneuvering. Health care is a personal issue for both men — to Mr. Sanders, it is a fundamental human right and embodies his lifelong message of economic equality. To Mr. Biden, who was vice president to Barack Obama when the Affordable Care Act was passed, it is also connected to the death of his son Beau Biden, who died after a battle with brain cancer.
Politically, polls show that health care is a top priority for Democrats, and an emphasis on protecting people with pre-existing conditions and reducing health care costs helped Democrats in last year’s midterms when they picked up 40 seats in the House. With Mr. Trump and Republicans repeatedly threatening to unravel Obamacare, Democrats hope that the issue of health care will again work in their favor.
If Mr. Sanders and Mr. Biden have both seemed at times to relish the debate, it has also thrown into sharp relief two competing visions for the Democratic Party.
Mr. Biden embraces fixes to the health care system and the addition of a public option, rather than a full-scale overhaul, portraying that approach as more pragmatic in today’s fractured political landscape, to say nothing of appealing to a nostalgia for the Obama era. The other view, championed by Mr. Sanders and others on the left, is that the nation’s challenges are so significant that only the boldest, most transformational proposals will do.
The philosophical clash erupted on Wednesday when Mr. Sanders delivered a formal address in Washington on the merits of replacing the current health care system with Medicare for All, saying his plan would “save lives” and urging presidential candidates to reject contributions from the health care industry.
Though he did not mention Mr. Biden by name, he took several veiled swipes at him, joking about how much Americans love their private insurance (they do not, Mr. Sanders claimed, though polls tell a more complicated story) and about how they love paying their insurance premiums (ditto).
Senator Bernie Sanders announced his Medicare for All plan in Washington on Wednesday.CreditSamuel Corum for The New York Times
It was a conflict that had been simmering for days.
Last week, Mr. Biden told reporters in Portsmouth, N.H., that Medicare for All is not “Medicare as you know it.”
“It is one that I think is going to be difficult to pass, No. 1,” he said. “But No. 2, I think people should be able to be in a situation, if they want to keep their employer-based insurance, they should be able to do it.”
Though Mr. Biden said that Mr. Sanders had been “very honest” about the costs of Medicare for All, he still drew a forceful rebuke from the Vermont senator, who accused Mr. Biden of echoing the insurance and pharmaceutical industries — and Republicans — in his criticisms of Medicare for All.
And on Monday, Mr. Sanders blasted Mr. Biden’s health care plan, suggesting it was aligned with “corporate greed.”
Aides to Mr. Sanders suggest the escalating confrontation plays into his hands: They have been trying to frame the primary as a competition between him and Mr. Biden, hoping to set up the same kind of insurgent-versus-establishment contrast that worked to Mr. Sanders’s advantage in 2016, when he was the foil to Hillary Clinton. And they view poaching supporters from Mr. Biden, particularly working-class Democrats, as the most promising way for Mr. Sanders to grow his base.
To help their case, they have been urging Mr. Sanders to go after Mr. Biden more aggressively.
Yet for weeks, they have remained frustrated with polls showing Mr. Biden still leading Mr. Sanders by comfortable margins, some allies said. The recent surges by Ms. Warren and Ms. Harris and the fund-raising prowess of Mayor Pete Buttigieg have also dispelled the notion that it is a two-person contest.
“He’s clearly losing support, both in the national polls and in states,” Stan Greenberg, a veteran Democratic pollster, said of Mr. Sanders. “He has no choice. I think he’s made a decision, he’s got to make himself relevant again. Health care was the issue in which he was relevant last time, and it was very important in the campaign in 2016, so I think it makes a lot of sense for him to try to draw this contrast on health care, particularly in the primary.”
Mark Longabaugh, who was one of Mr. Sanders’s top advisers in 2016 but left the 2020 team this year, said Mr. Sanders was “really good in a contrast.”
But he cautioned that the senator would be ill-advised to discount his other opponents at this point.
“You’ve got obviously several other significant candidates and actors in this thing,” he said. “I just don’t see this election turning into a Biden-versus-Bernie race.”
Mr. Biden’s allies point to the current political realities in Washington — which includes a Republican-controlled Senate — as evidence that passing a sweeping overhaul of the nation’s health care system would be exceedingly difficult, and argue that Mr. Biden’s proposal is more realistic.
“I’m not so sure anyone believes Americans are ready to go through a wholesale change in the health care system,” said John Anzalone, a Biden pollster. “Joe Biden is approaching this as, people are hurting, what can we do now, or in the very near future, when a Democrat is president?”
In a separate interview over the weekend with The New York Times, Mr. Sanders appeared to acknowledge the steep political requirements of his proposal, saying “a Democratic Senate is certainly absolutely imperative if we’re going to go forward,” and added that members on both sides of the aisle would have to come together to create “a system which is designed not to provide huge profits for the drug companies and the insurance companies but quality care to all people.”
As the battle over health care continues, even Mr. Sanders’s advisers are no longer hiding their distaste for Mr. Biden’s criticisms.
“This campaign will not be a punching bag for misinformation out of the Biden campaign,” said Jeff Weaver, Mr. Sanders’s 2016 campaign manager and his closest adviser.
Referring to the last presidential contest, he added, “If people want to go into the general election in 2020 with a candidate with the same set of policy prescriptions as 2016, that’s a real roll of the dice.”

Why the House plans to pass a bipartisan bill repealing a controversial Obamacare tax

The Cadillac tax is on the chopping block.
by Tara Golshan - VOX - July 17, 2019 
The House of Representatives is about to pass a bipartisan health care and tax bill Wednesday to get rid of a long-hated part of the Affordable Care Act: the “Cadillac tax.”
The Cadillac tax levies a 40 percent tax on the most expensive employer-sponsored health insurance plans, those worth about $11,200 for individuals and $30,100 for families, starting in 2022. The tax on businesses would hit the part of the plan above the price threshold. It was supposed to go into effect in 2018 at a lower price threshold, but was delayed. Repealing the tax would cost the United States an estimated $197 billion over 10 years, according to an analysis by the Joint Committee on Taxation.
The House bill, the Middle Class Health Benefits Tax Repeal Act of 2019, has more than 350 co-sponsors and is expected to pass with bipartisan support. While Senate Republicans have shown interest in the bill, it’s not clear whether Senate Majority Leader Mitch McConnell will bring the bill up for a vote.
The Cadillac tax has been a controversial provision in Obamacare from the beginning — and almost by design. Its passage resulted in some strange ideological bedfellows. In 2008, John McCain campaigned on it. Obama’s advisers endorsed it. Sen. Marco Rubio included a Cadillac tax in his 2015 Obamacare repeal proposal. But in the 2016 presidential election, both Hillary Clinton and Sen. Bernie Sanders called to repeal it. Advocates for repealing the Cadillac tax include conservative chambers of commerce and big business.
But the issue remains divisive among Democrats and Republicans, even within their own parties.

The Cadillac tax was always controversial — and unpopular

The point of this tax was to encourage employers to offer less expensive health insurance. Sarah Kliff explained why for Vox in 2015:
Traditionally, the government doesn’t tax employer-sponsored insurance. This has created a huge incentive for companies to spend more money on generous insurance plans and less on cash wages. This, in turn, pushes up health-care costs across the system. When workers have expensive plans with no copays or deductibles, they’re likely to use lots of health care, including trips to the doctor they don’t really need.
The economists and policy advisers under the Obama administration who supported the Cadillac tax argued that by encouraging companies to scale back insurance benefits, businesses would in turn give employees a wage increase (there’s some evidence that could happen). And, they said, it would only hit the wealthiest executives, most generous union plans, and major companies (which there’s not much evidence to support).
At the end of the day, the Cadillac tax was literally designed to encourage companies to make insurance plans worse. Not necessarily terrible — but just to reduce benefits and control costs.
“The Cadillac tax is one of the most important tools we have to control health care cost growth in the private sector,” the Committee for a Responsible Federal Budget, a deficit reduction think tank, said in a statement. “Repealing it will drive up health care costs while adding more than $1.2 trillion to the debt over the next two decades and reducing wages by trillions over that time period.”
That said, according to a 2018 study by the Kaiser Family Foundation, increases in deductibles for insured workers have outpaced any real wage increases for employees. So it makes sense that both businesses that would have to pay the tax and labor unions who negotiate generous health benefits for their members argued against it.

The Cadillac tax had some fundamental flaws

Advocates for the tax’s repeal point out a few fundamental problems with it.
First, it’s not just rich corporate bosses getting robust health care package; it’s teachers, state workers, and other employees who aren’t necessarily ultra-high earners. As Kliff writes that the Cadillac tax is a “blunt instrument”:
There’s no adjustment, for example, for people who live in places where health care is really expensive — so the threshold is the same in the Midwest, where health insurance is pretty cheap, as it is in remote states like Alaska, where it’s more expensive to deliver health care. It’s the same for teachers as it is for bankers, for someone who has a chronic disease that really does require many doctor visits and for someone who is perfectly healthy.
Second, the way the tax is set up means it could affect more and more plans down the line. As written, the price threshold under the Cadillac tax rises with the rate of inflation. So in 2022, an analysis by the Kaiser Family Foundation found, 21 percent of employers would face the tax. But by 2030, 46 percent of employers would be hit.
That’s because health care costs typically grow faster than the economy. While in 2017, health care spending grew at nearly the same rate as the economy, last year the government projected that health care spending would rise by an average of about 1 percentage point faster than economic growth annually through 2026.
That means that down the road the Cadillac tax would no longer be on just the most expensive plans. It would hit much more than that.

Blue Cross’s approach to paying doctors based on quality of care shows results, Harvard study finds - The Boston Globe

by Shirley Leung - Boston Globe - July 18, 2019

The study published Thursday in the New England Journal of Medicine is the longest evaluation to date of this type of payment model. With eight years of data, it adds to the body of evidence that suggests changing incentives for doctors and hospitals could moderate costs.
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Rising health care costs are a perpetual concern in Massachusetts and across the country, and many experts believe spending growth will not let up unless the payment system changes.
“This contributes to a growing sense that smarter ways of paying for health care are going be to an important part of the solution to rising health care costs,” said Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, who was not involved in the study.
Doctors and hospitals traditionally have been rewarded for every test, procedure, and service they provide, regardless of whether those things help patients get healthier.
Blue Cross’s payment program, called the Alternative Quality Contract, has been closely watched since it began in 2009. Other insurers, including Harvard Pilgrim Health Care and Tufts Health Plan, have since launched similar programs.
The federal government has also pushed new payment plans in Medicare through accountable care organizations: groups of doctors and hospitals that work together to coordinate care for patients. And in Massachusetts, the Medicaid program for low-income individuals is in the midst of similar changes.
The programs all share two lofty goals: improve patient health and slash costs.
The Harvard study shows that spending increased for patients in the experimental Blue Cross program — but it grew more gradually than spending for other patients. The savings may be too modest for patients to notice in their health care premiums, which generally continue to rise.
The program was linked to an average 12 percent savings on medical claims over eight years. Some of the savings came when patients shifted their medical care to less expensive facilities. Costs also moderated because patients used fewer services; for example, they received fewer expensive MRIs and visited hospital emergency departments less frequently.
At the same time, the quality of care they received stayed steady or improved, said Dr. Zirui Song, the study’s lead author. Quality was calculated through a variety of measures, including whether patients received the proper cancer screenings, and whether they maintained a healthy blood pressure.
Song said his analysis shows that alternative payment programs are sustainable over several years. But he cautioned, “Behavior change is difficult, and sustaining behavior change is even more difficult.”
The study, funded by the National Institutes of Health, was welcomed by executives at Blue Cross, Massachusetts’ largest private health insurer.
“For so many years, the health care field was really paralyzed by the belief that controlling costs would actually harm quality,” Blue Cross chief executive Andrew Dreyfus said. “What this study again reinforces is with the proper incentives, you can control costs and improve quality.”
The Blue Cross program and others like it differ from earlier experiments in payment reform because of their emphasis on quality measures. Blue Cross requires doctors to score well on dozens of different measures before they can earn bonuses.
In the 1980s and 1990s, “there were concerns about doing too few things — like people would not do a cardiac bypass procedure because it would be too expensive,” said Dr. Steven Strongwater, chief executive of the physician group Atrius Health. “What these measures have done is erase that risk, by virtue of the fact that you’re measuring outcomes.”
The Blue Cross program gives doctors special funds to invest in care management. Atrius — among the first medical groups to join the Blue Cross program — used some of that money to hire new care managers who worked with patients to control their blood pressure. In 2009, 65 percent of Atrius patients had blood pressure in a healthy range. A decade later, that has grown to 85 percent.
Meanwhile, Atrius — which includes Harvard Vanguard and other physician practices — is also working to save money by moving common surgeries, such as joint replacements, from hospitals to ambulatory surgery centers.
Alternative payment programs account for about 41 percent of patients with private insurance in Massachusetts, according to state data. The popularity of these programs varies in other states, and nationally, the traditional fee-for-service payment system remains the norm.
Massachusetts has been more aggressive than other states in taking on health care costs. It set a target — 3.6 percent — for controlling annual increases in total statewide health spending. It also created a new watchdog agency, the Health Policy Commission.
In 2017, the most recent year for which figures are available, total health care spending in Massachusetts increased 1.6 percent — the lowest level in five years — even though costs remained a burden for many patients.
Dr. David Blumenthal, president of the New York-based Commonwealth Fund, a nonprofit that does health policy research, said the Harvard study demonstrates that payment reform is a critical piece of the strategy to control costs.
“We generally don’t give experiments in health system reform enough time to prove themselves,” Blumenthal added. “This is an eight-year study, which is unusually long for a social experiment. It shows we may have to wait a certain amount of time to reach judgment in the experiments we launch.”

Tuesday, July 16, 2019

Health Care Reform Articles - July 16, 2019

Are Americans just too different to ever finally adopt publicly-funded universal healthcare? 

By Henry Broeska, July 12, 2019
Over the past few years I’ve frequently been asked by some of my American colleagues whether or not I believe single payer healthcare the way Canada came to adopt it has a chance of success in the United States. Just as the Medicare-for-All movement is gaining momentum, there remains substantial public opposition to it in many quarters. My friends point out that if it was ever to happen, it would have happened by now that Canadians have been socialized differently and therefore are more approving of a public universal healthcare system. After all, Canadians enthusiastically accepted their form of Medicare without any of the political wrangling that has characterized American attempts to achieve it over the past 75 years. All good points.
I think most people assume that Canadians are just a sub-group of Americans with the same core beliefs anyway. Because I’ve lived and worked in both countries, I’m acutely aware of the significant social divide that exists between Canada and the US. But there’s nothing to prevent Americans from passing Canadian-style healthcare reform legislation if that’s what they want, right? Nevertheless, the question still nagged at me “What if my friends are right,” I thought. “What if universal, publicly-funded healthcare can’t be achieved because of an important way Americans are different than people in other countries?”
I concluded that I was probably too biased to answer that question without developing a thesis. I needed to spend some time examining the crucial differences between Canadians and Americans that may expose an inconvenient truth: that any broad-based national consensus on a publicly-funded, single payer healthcare program may not be possible. And even if by the collective will of voters, the greatest policy change in American history occurs, there is sure to be intense and continuing opposition to it. In our divided country, laws that can be made in one political cycle can be abolished in the next by the opposing party or ideologically-motivated courts. So in looking at this question, I decided to start with the documents that gave each country its laws.
Merciless Indian Savages
A nation’s fundamental beliefs are the values and sentiments it formally articulates in its constitution. And it’s also where we find the first major difference between Canada and the US.
In 1984, the new Canadian Constitution identified “peace, order, and good government,” (this was language lifted directly from the antecedent British North America Act of 1867) 1 as the three guiding principles held to be the nation’s highest ideals. Two hundred years earlier, the United States framed “Life, Liberty and the pursuit of Happiness” as “unalienable rights” held to be “sacred and undeniable.”
Canadians more or less live up to the three less dramatic and achievable precepts written into their Constitution. In contrast, the American ideal is both aspirational and
hypocritical. To begin with, slavery was legal in all 13 colonies that formed the union around the time those words were written and didn’t disappear in the southern states until after the Civil War.
I have some questions of the men who wrote those words because I don’t know what they mean. Were black slaves considered in the “liberty” and “happiness” directives? That is, were they considered to be “human?” Did the concept of “unalienable rights” apply to the “merciless Indian savages” also a three-word term, there for all to see forever in the language of the Declaration of Independence? While it took a bloody civil war to erase slavery, racial injustice has never disappeared. Jim Crow laws 2 were encoded in the law for a century after the American Civil War. And almost two and a half centuries later, the average black family in America is still ten times poorer 3 than the average white family.
Meanwhile, north of the border, Canada wasn’t challenged by the need to invent a constitution by way of revolution as was the US. Neither did the country build its economy on the backs of slaves. After 1783, British North America remained steadfastly British with close societal and legal ties to England right up through the mid-twentieth century. The English class system very much dominated the Canadian social structure with political roles for the elites. Its laws remained faithful to the continuation of British colonial culture. Peace and order through respectful, dignified, and reserved behavior were prized above all other traits. Canadian separation from Britain occurred gradually through negotiations, and without the need for a violent ‘Revolution.’
Already we see a large gap opening on our Canada/US cultural variation scale.
“Canada is the only country in the world that has learned to live without an identity.” ― Marshall McLuhan
Early Canadians, mostly of North England and Scottish heritage, were religious, hard- working, stoic and rigidly conformist. Despite all efforts, from the 1600s right through the late 1800s, it was by no means a safe bet that Canada as a country would endure. For example, new public infrastructure had to be built over wild, vast, and unpopulated landscapes. Canada wouldn’t have been able to maintain its country status without nearly impossible engineering feats. Survival in an inhospitable northern climate meant that people had to cooperate in every area of society for the common good.
While Canadians were practicing their English sensibilities and cooperating as a social survival strategy, Americans were behaving much differently. Colonial brutality towards other cultures seems to be historically forgotten, or ‘reframed’ as justifiable while never recognizing the hypocrisy of labelling Native Americans “merciless Indian savages.4 Harvard Professor Bernard Bailyn has devoted an entire book to historical violence visited upon other cultures going back to America’s earliest days. He believes that the “peaceful Pilgrims” set the tone for all future American behaviors. In recalling accounts of the Pilgrim’s systematic extermination and enslavement of the Pequot Tribe of Native Americans in Connecticut, he says: “a legacy of brutality in intercultural relations developed through this period of which, of course, the overwhelming legacy was slavery.” He went on to add, that with these early acts of savagery, “The rules for chattel slavery were set.” 5
The American perspective: owning a gun is a right; access to healthcare is a privilege
Perhaps the most factious constitutional issue that survives today is the uniquely American right that allow individuals to own firearms. Constitutionally protected ‘gun rights’ are representative of the important way Americans are different than any other people on the planet. There was a time when guns were a necessity for rural-based people. Historically, Canadians as much as Americans used guns as readily as plows or pitchforks as tools to settle their expanding frontiers. But that need for guns ended for urbanized Canadians in a way it didn’t end in the US. So what do guns have to do with healthcare?
‘Healthcare’ too is an important right written into many modern constitutions after the passage of the United Nations’ Universal Declaration of Human Rights (UDHR) in 1948. Modern medicine had advanced to the point that after 1948, many countries’ constitutions were either written anew or updated to reflect healthcare as a human right. But the US Constitution wasn’t amended even though ‘healthcare’ as it is practiced today didn’t exist in 1776. Two centuries ago, primitive medical practices couldn’t be relied upon to cure diseases or save lives. The founders couldn’t have known of the future importance of ‘healthcare.’ On the other hand, gun rights today remain
constitutionally entrenched just as if they are still essential to arm a civilian militia made up of shopkeepers and farmers to protect a fragile nation.
Stone tablets
Fearing a breakdown of the political deals that aggregated the new states into a fledgling country, the founders made it effectively impossible to amend the US Constitution to reflect changes in society, even ones that demand a break with the past. The President recently justified continuing private ownership of assault weapons by saying that Americans need them for “entertainment” — a frivolous use that the founders never envisioned, and never would have endorsed. 6
Would the founders have added ‘healthcare’ had they been able to recognize its importance to a burgeoning nation? Did they mean for the constitution to remain unchanged for all time?
Without a need to defend against foreign threats, hunt food, or snipe varmints from the front porches of our urban homes, the country's historic need for guns has morphed into something else, something that exposes a darker side of American values today. My neighbor across the street in California recently confided that he owns dozens of handguns and assault weapons, and keeps them on his premises. He told me that he isn’t a collector, and he doesn’t feel threatened; in his words, “I just like guns.”
“The guns and the bombs, the rockets and the warships, are all symbols of human failure.” Lyndon Johnson
In my observations I have come to believe that many Americans enjoy owning guns, not for reasons of need, principle, or self-defence, but because it is a kind of self- actualization. From an American perspective, “gun ownership is normative, not deviant behavior across vast swaths of the social landscape.” 7
I point out this difference because Canadians consider that using personal firearms outside of their limited, modern-day purpose is the ultimate aberrant behavior. In Canada, the number and type of guns owned by my neighbor would be a criminal matter. The police are the ones who are supposed to be armed to protect the country’s citizens. This belief makes for a rather orderly society with the capacity and prerogative to argue for constitutional rights that are more practical and socially useful like healthcare.
“Polarizing people is a good way to win an election, and also a good way to wreck a country.” ― Molly Ivins
Americans have historically demonstrated a cycle of polarized opinions that results in catastrophic outcomes; a civil war, baseless foreign wars, assassinations of political figures, unstoppable domestic mass shootings, a continuation of racist policies, and complete gridlock in the political process. Most times the US Constitution is invoked as justification for one deviant action or another. Today, the United States is at the height
of one of those cycles of polarized opinions that’s revealing the cruelty inherent in our national personality.
Yet lawmakers continue to venerate the US Constitution as if it was Divine Law handed down by God on stone tablets. The divinity bestowed upon the US Constitution, the national values of violence and racism it maintains, the elite dominance of a minority over a majority, and the difficulty in ever changing it now reveals a much wider cultural gap between Canada and the US.
But wait. There’s more...
Canada’s great social experiment
Canadians have no history of clinging to constitutional ideals so tightly that it results in breakdowns of law and order or violence. But I believe it was the three constitutional principles of “peace, order, and good government” that might have predicted how universal healthcare came to happen.
Western Canada became a kind of Petri dish for Canada’s version of nation-building, and particularly, universal healthcare. By the time the transcontinental railroad had pushed west in the 1880s, Canada needed an immigration boom to populate the country and grow the economy. Fleeing the tyranny of communism and famine, western Canada was filled by non-English-speaking eastern and northern Europeans, mostly farmers. They found safe harbor on the rich agricultural soils of Manitoba, Saskatchewan and Alberta (collectively, the Prairie Provinces).
New Canadians were freely encouraged to practice their religions and cultures, but in terms of social order, it was decidedly British. The centuries-old colonialization practices of Britain were useful for achieving the civilizing mission in a domestic quasi- colonial setting albeit with a Canadian flavor. The settlers learned English and British customs while a photograph of the Queen beamed down on their children in every school classroom. No longer under despotic rule, the new equality they claimed allowed them to welcome the authority of Canada’s British version of government and Common Law, along with respect for its customs and social order.
The political power behind this Canadian experiment was always a self-proclaimed group of elites of mostly English and Scottish origin. There were well-heeled French- Canadian families in the mix. They bestowed upon themselves control of key Canadian industries; banking, grain, forestry, mining, oil and gas, transportation, and manufacturing. To this day, some have kept their hereditary peerage titles, a vestige of their British heritage. In future generations their sons, grandsons and great-grandsons still run the political bureaucracies as well as some of the academic institutions (the Trudeau family is an example Americans would recognize).
The social policies they brought forward tended to be for the common good, not themselves. This common goodfocus took precedence over the ‘individual rights’ angle preferred in the United States and embraced in their constitution. Lest there be temptation to pass laws that benefitted the elite class over another, a new, highly-
motivated democratic socialist political Party led by Tommy Douglas, an immigrant Scot himself, kept them honest.
The concept of public universal healthcare was proven on the wheat fields of Saskatchewan using this cultural mixture of new Canadian immigrants. And it was Tommy Douglas, founder and first leader of the New Democratic Party (the NDP), who pioneered the first universal healthcare legislation in North America. There is little doubt that this is legislation that wouldn’t have been enacted without a democratic socialist perspective. Like the US, Canada had primarily a two-party system up until the formation of the NDP in the early 1960s. This third social democratic party, often called “Canada’s conscience,8 has no equivalent in the United States. The socially progressive policies that came out of the western Prairie Provinces allowed the Tommy Douglas-led federal New Democratic Party to force the national adoption of publicly- funded healthcare and many other social programs.
Progressive Canadian governments recognized that vulnerable people, through no fault of their own, cannot fully participate or progress if they cannot overcome their health problems. Not only was public universal healthcare the right thing to do, it was economically valuable for the country. An economic benefit/cost analysis demonstrated that universal healthcare saves money because healthy workers are happy and productive taxpayers, not a social burden. As a service to a grateful nation, there was really no argument that could be made against it.
Once universal healthcare was proven to work in Saskatchewan, the leaders of the three federal parties with opposite ideological beliefs saw that they had no choice but to work together to make it happen nationally. Medicare became so popular with Canadians that anything less than a ringing endorsement would have seen the dissenting party wiped off the political map.
Here in the US, the Progressive wing of the Democratic Party is just now starting to represent some of the policies of the Canadian NDP of 50 years ago. If Medicare-for-All is to happen, it will be this group of progressives who leads the way. They’ve got their work cut out for them. They are stuck inside a middle-of-the-road party that will prevent their most progressive ideas from ever becoming party policy. So how on earth will it be possible to convince an entire country to vote for radical health policy reform if they can’t get their party’s full backing?
This is the point at which the cultural gap between Canada and the United States really turns into a chasm. To complete the picture, I need to finally demonstrate that Canadian commitment to justice, fairness and equity go a lot further than health policy. What most Americans don’t understand about Canada would make their heads spin.
Pierre Trudeau’s “Just Society”
For Canadians, progressive policies didn’t end at universal healthcare. The Liberal government of the 1960s instituted some remarkable changes in the social order. The move to the left was not forced upon the country by disgruntled youth protesting a foreign war or marching against racial injustice. It was started by a new generation of
political intellectuals led by young Prime Minister Pierre Trudeau (father of current PM, Justin). Trudeau had a vision for Canada, which he called a “Just Society.” 9 Upon assuming the role of Prime Minister, his speech began with the words: “No one in the society should be entitled to superfluous or luxury goods until the essentials of life are made available to everyone.” It would be hard to imagine any American politician, much less their nation’s leader ever making the same public commitment to equity.
Trudeau’s “Just Societyexpression was not simply an opportune catch-phrase. Canada’s 60s shift toward liberalism engendered policies and practices that fundamentally changed Canada forever. As Americans struggled with their internal race relations, Trudeau’s government deliberately began welcoming more brown skinned people from around the world as it tried to secure the country’s economic future. As a first step to avoid the possibility of racial discrimination, the government formalized the policy of multiculturalism. 10 Trudeau’s government also redefined capitalism to mean social democracy, which is capitalism with an ambitious set of rules and social programs that safeguard the rights of subordinate social groups.
“The past is to be respected and acknowledged, but not to be worshipped. It is our future in which we will find our greatness.” Pierre Trudeau
Other progressive Trudeau government programs were: subsidized secondary education and vocational training to stream young workers into the workplace; college and university tuition costs are a fraction of what they are in the US. Once graduates got into the workplace they were protected by strict anti-harassment and anti-discrimination laws with severe penalties for hate-speech and hate-crimes. Unemployment insurance benefits were expanded to match workers with a living wage for as long as they remained unemployed. Paid vacations became law, and sick days could be banked. For raising kids, there were a number of programs including a child tax credit, which is paid directly to parents to help defray the cost of raising each child. In addition, the government created federally-mandated paid maternal and paternal leave of 12-months. 11 Today there are many more health-related and social programs outside of the healthcare system itself. As long as I can remember, Canada has added, not subtracted social programs. Trudeau’s government or not, social equality has always been in Canada’s DNA.
Canadians understand that social prosperity isn’t simply a monetary measure of wealth or income. True prosperity in society is a collection of fair resolutions to the challenges that everyone faces from time to time. The aggregate wealth of the country must be applied to circumstances of need and by the mid-twentieth century Canada had become one of the wealthiest countries in the world thanks to its hard-working people. All of these social programs are rewards for the people’s contributions to their country’s prosperity. They were designed to help all Canadians achieve full potential or catch them if they stumble a kind of social contract.
The outcome of the Canadian experience has been a relatively un-stressed, compassionate and non-agitated national population. It highlights perhaps the most important difference between Canada and the US: Canadians are predisposed to trust
authority and see government as a good thing, while Americans are suspicious of their government and see it as a necessary evil.
Canada mirrors most other countries in the developed world. It’s the United States that is really quite different from the rest, and many of those differences end up producing negative and even life-threatening consequences for a growing number of people. While Canada is still broadening its social safety net, the United States is tearing theirs apart. Social welfare programs have been cut back and re-investment in education and infrastructure have been curtailed. Instead of keeping progressive taxation, the government has lowered taxes for the elite class. And while the US government promotes free market policies as a benefit to all, deregulation, de-unionization, and a declining manufacturing base have resulted in both wage decline and wage inequality. The current Administration’s disengagement of regulations, actions and policy changes will have negative social consequences for years, if not decades.
“Sadly, the American dream is dead.” Donald Trump
Anger with a paralyzed American political system elected a demagogic President who successfully reflected that anger back upon a resentful white electorate as if it was consecration of their feelings. In doing so, for many, he turned himself into an untouchable folk hero who no can longer be judged on his corruption, his lies, his racism, or his immoral lifestyle of excess. Americans used to be famous around the world for their pragmatism and good old American ‘know-how.’ As social and political norms are shattered daily, the global perception of Americans is that they have become a highly agitated people with extreme views given to lunatic conspiracy theories.
Americans have been told that the biggest threat to the country is brown-skinned mothers and their children fleeing poverty and domestic terrorism and claiming asylum in the United States. While our attentions are being misdirected to the southern border, tens of millions of Americans struggle with paying their medical bills and getting timely access to treatments. Through it all we are warned daily that a public health insurance plan covering everyone will destroy our American way of life. (and that would be a bad thing, why?)
So misplaced is our anger towards new, protective social services, that it’s inevitable there will more venting and lashing out at attempts to create a national public health insurance scheme. It’s incredible to think that in a healthcare system as dysfunctional as this, many believe that a public plan will be worse. Unfortunately Americans conflate ‘social programming’ with ‘socialism.’ They don’t realize that invoking the term ‘socialism’ is a tried and true way for corporations and their political surrogates to keep the social order and maintain a particularly ugly brand of capitalism.
I hope this short discussion gives the reader a sense of how far out of touch the US is with the rest of the world. In times of prosperity, governments of most other developed nations work earnestly to provide more rights and protections for their citizens. A universal healthcare plan is the ultimate protection that developing countries strive to achieve for their citizens. But despite this time of unprecedented economic growth, that
is not happening in the United States. While offering no new programs or benefits, and in fact, removing protections for the most vulnerable in our society, the current leadership instead blames every past and future shortcoming in our country on displaced people of color.
In such a collective confused, depleted and unresourceful state of being, the question remains whether Americans could ever agree to adopt a healthcare system like Canada’s, even if we know it saves lives, money, and a lot of needless pain. If we do, it will come to Americans in a much different way than it came to Canadians.
Perhaps we will have an age of enlightenment after the darkness of these past years, which will inspire a sea-change in thinking. But we can’t depend on that. Unfortunately, I believe that healthcare reform will only happen when enough Americans feel more pain. How many more and how much pain is the question. Far more educational work must be done before a national publicly-funded healthcare system will seriously be considered by either the American electorate or lawmakers.
Ultimately, it may come down to individual progressive states trying to save themselves if local lawmakers can loose themselves of their corporate masters. What the constitution takes away by allowing elite minority dominance, it also attempts to give back through states’ rights, a kind of local counter-balance to federal authority. This route hasn’t been tested before for such a major policy piece but because of the mighty corporate forces against the national Medicare-for-All movement, the only path to healthcare reform may well be through the states, just like it was through the provinces in Canada. But there the similarity ends. In the meantime it will take advocacy, activism, and eventually, mass civil disobedience to force healthcare reform. This does not preclude the possibility of violence. In America, ‘twas ever thus.
  1. Gall, Gerald L. and A. Anne McLellan. "Peace, Order and Good Government". The Canadian Encyclopedia, 26 October 2017, Historica Canada. government. Accessed 11 July 2019.
  2. Wikipedia contributors. (2019, July 8). Jim Crow laws. In Wikipedia, The Free Encyclopedia. Retrieved 22:26, July 11, 2019, from
  3. Jan, T. Black and Hispanic Families are making more money but they still lag far behind whites. Washington Post 28 October 2017 hispanic-families-are-making-more-money-but-they-still-lag-far-behind- whites/?noredirect=on&utm_term=.bc84bd8435ab
  1. Carocci, Max. “Written Out of History: Contemporary Native American Narratives of Enslavement.” Anthropology Today 25, no. 2 (April 2009): 15–20. Link.
  2. Rosenbaum R., The Shocking Savagery of America’s Early History. Smithsonian Magazine. March 2013. shocking-savagery-of-americas-early-history-22739301/?no- ist=&amp=&page=3&webSyncID=ea1db281-38d6-4873-5437-20c4932ea9a7
  3. Christopher, T. Trump Says People Need Assault Weapons Used in Mass Shootings for ‘Entertainment.’ Media ITE Jun 5th, 2019, used-in-mass-shootings-for-entertainment/
  4. Wright, J. D. (1995). Ten essential observations on guns in America. Society, 32(3), 6368.
  5. Bell, D. And now a word from our NDP conscience. The Globe and Mail. Published April 12, 2011, updated May 3, 2018 word-from-our-ndp-conscience/article613379/
  6. Wikipedia contributors. (2019, July 8). Just society. In Wikipedia, The Free Encyclopedia. Retrieved 17:32, July 12, 2019, from
  7. Wikipedia contributors. (2019, June 12). Multiculturalism in Canada. In Wikipedia, The Free Encyclopedia. Retrieved 22:45, July 11, 2019, from =901565586
  8. Government of Canada website. EI maternity and parental benefits: What these benefits offer. Retrieved July 11, 2019 

Erasing Obamacare Could Undermine Trump’s Own Health Initiatives

by Margot Sanger-Katz - NYT - July 11, 2019

In court, the Trump administration is trying to get all of Obamacare erased. But at the White House, President Trump and his health officials are busily using the law to pursue key proposals.
Last week, the president highlighted a policy in the works meant to narrow the gaps between what drugs cost in the United States and overseas. On Wednesday, he signed an executive order to transform care for patients with kidney disease.
Both measures were made possible by a provision in the Affordable Care Act, and both would be effectively gutted if the administration’s position prevailed in court.
In between, administration lawyers told a receptive panel of judges in New Orleans that the entire Affordable Care Act should be overturned.
“What they’re doing now is tolerating this ambiguity between the flat-out rhetoric of ‘repeal Obamacare’ and the reality that they love many aspects of what was enacted in the Affordable Care Act,” said Dan Mendelson, the founder of the health care consulting firm Avalere Health.
The crucial provision is known as the innovation authority. It allows Medicare and Medicaid to test strategies for paying for medical care in pursuit of ways to lower costs and improve the quality of care.
It is a very broad authority. Before Obamacare, most changes to Medicare required special legislation from Congress. Congress can move slowly, and medical industries tend to oppose provisions that would result in less spending on treatment. With the innovation authority, the Department of Health and Human Services can introduce various experiments, and it has the power to take successful pilot programs national, without involving Congress.
That’s a power that has been welcomed in an administration that has embraced broad executive power. Obama administration officials liked the innovation center power, too. But the Trump administration has gone further, experts said, in pursuing a variety of interesting ideas about how to reform health care delivery.
Alex Azar, the secretary of Health and Human Services, has pointed enthusiastically to this authority at times, telling reporters last year that his “pen has a lot of power.”
When asked about the court case Wednesday, Seema Verma, a top deputy in the department, told Anna Edney at Bloomberg News that the department had a “plan in place” to preserve some parts of the health law even if the court overturned it. She mentioned the innovation authority specifically but did not give details on the plan.
Wednesday’s announcement on changes in kidney care featured an executive order and a speech from the president. But the meat of the proposal was four demonstration projects begun under the innovation authority. One was devised to reshape how kidney care providers are paid and would affect around half of all patients with renal disease, a sweeping change.
The president talked about another top health care priority last week: his desire to lower the cost of prescription drug prices. He mentioned a policy under review that would make some of the prices charged by drug companies more aligned with those in other developed nations. That proposal, too, was authorized under the Affordable Care Act’s innovation authority and would otherwise require a new law.
Other areas of experimentation include surgery, primary care and cancer treatment. Ashish Jha, a Harvard professor who studies changes in the health care delivery system, said the Trump administration had been ambitious and creative in trying new ways to use payment experiments to nudge medical providers toward higher-quality care.
But the administration’s position in court could jeopardize all those initiatives. If the Affordable Care Act is overturned, as government lawyers have pushed for, the innovation authority will go with it.
That outcome would undermine large parts of the administration’s health care agenda, Dr. Jha said: “I think the administration is going to be very hobbled in terms of their efforts to really improve the delivery system.”

Biden unveils health plan, sharpening fight among Democrats

by Sean Sullivan - Washington Post - July 15, 2019


Joe Biden unveiled a proposal Monday to expand the Affordable Care Act with an optional public health insurance program, escalating a fierce debate with his Democratic rivals who favor a more sweeping Medicare-for-all system.
Biden’s plan, which campaign officials estimate would cost $750 billion over 10 years, would also expand tax credits to pay for health premiums, and it would create a new coverage option to help people living in states that have resisted the ACA’s expansion of Medicaid.
The plan, which formalized ideas Biden has campaigned on for months, sharpens one of the biggest dividing lines in the Democratic presidential primary. One on side are traditional Democrats such as the former vice president, who warn that scrapping President Barack Obama’s signature health law could have dire consequences. On the other side are liberals such as Sen. Bernie Sanders (I-Vt.), who argue that a complete health-care overhaul is necessary to achieve universal coverage.
“I understand the appeal of Medicare-for-all, but folks supporting it should be clear that it means getting rid of Obamacare, and I’m not for that,” Biden said in a video released by his campaign. “I was very proud the day I stood there with Barack Obama, and he signed that legislation. . . . Starting over makes no sense to me at all.”
The dispute between Biden and Sanders, who in many ways represent the ideological poles of the Democratic field, has ramped up is recent days. Biden said he had “profound differences” with Sanders and another candidate on health care and suggested their approach could imperil people’s coverage, prompting Sanders to forcefully rebut him. And Sanders plans to deliver a speech Wednesday to confront opponents of the single-payer, government-run plan he has long championed.
Biden’s team signaled he is ready to embrace the fight, even if it risks alienating some in the party’s liberal base, suggesting that a fight over an unattainable goal will only undermine badly needed improvements in the short term.
“You’ll see him make a case about the urgency of now, that starting over from scratch is not the way to ensure that people in this country who need more affordable coverage are going to be able to get it,” said one of the senior Biden campaign officials who previewed the plan ahead of its release.
Disagreements over health care, an issue that polls show is important to many voters, loom heavily over the general election as well. Many Democrats are eager to reprise their successful midterm strategy of pointing to Republican efforts to repeal and replace the ACA. President Trump and his allies are looking to counter with attacks casting Medicare-for-all as a scary takeover of the health-care system that would be detrimental to many Americans, a line of attack that worries some Democrats.
With AARP hosting a series of candidate forums this week in Iowa, and the next Democratic debate coming up at month’s end, other candidates are also seeking to clarify their positions on health care. Sen. Cory Booker (D-N.J.) will release a proposal Monday to allow more people to be eligible for Medicaid services.
Biden, who leads the crowded pack in state and national polls and is running heavily on the Obama record, faces particular pressure. Among other things, he hopes to turn the page on a series of controversies — most notably his comments praising his past work with segregationists, which he recently said he regretted.
At the heart of Biden’s health-care plan, which senior campaign officials said would cover more than 97 percent of Americans, is a proposal to let people choose a government-run health system like Medicare if they aren’t happy with private insurance. Obama initially set out to include such a public option in the ACA law, but later backed away from the idea amid political resistance.
The former vice president would bolster other parts of the ACA designed to help people purchase insurance. It would get rid of the income cap — 400 percent of the federal poverty level — used to determine who qualifies for tax credits that help Americans pay insurance premiums.
Biden’s plan would also seek to circumvent the resistance by many Republican-led states to accepting the expansion of Medicaid, a program for low-income and disabled Americans. In the 14 states that have not expanded Medicaid as allowed by the ACA, Biden’s proposal would let those who would otherwise qualify for assistance buy into the public option without premiums.
Abortion rights are also part of Biden’s plan. He would provide federal funding for Planned Parenthood and combat the actions of states that have moved to tighten restrictions on abortions. And the overall plan would be funded by raising taxes on the investment income earned by wealthy Americans.
After initially aiming most of his fire at Trump, Biden now appears eager to contrast his position on health care with his Democratic rivals. Many centrist Democrats fear that if the party’s nominee embraces Medicare-for-all, including the sidelining of private health insurance, it will scare off many voters and play into Trump’s hands.
Of the four Democrats leading in the polls, only Biden wants to build on the ACA rather than push Medicare-for-all. Sens. Elizabeth Warren (D-Mass.) and Kamala D. Harris (D-Calif.) are largely following Sanders’s approach.
Campaigning in New Hampshire last week, Biden said it “took a long time to get us to where it is now,” referring to the decades-long battle to pass health-care restructuring. Too many people are at risk, he warned, to go through another lengthy debate about overhauling the system.
He went after proponents of Medicare-for-all both directly and obliquely. Biden said Sanders has “been very honest” about raising taxes on the middle class to pay for his plan and ending private insurance, suggesting those ideas are political poison.
Sanders acknowledges his proposal would require tax increase on middle-class Americans, but he argues that they would pay far less in health-care costs, saving them significant money overall. And while his plan would bar private insurers from replicating services covered under Medicare-for-all, he has said they could still finance elective procedures.
The debate over private insurance has been complicated. Some candidates have tried to walk a fine line, endorsing Sanders’s plan while trying to avoid alienating Americans who want the option of keeping their insurance. Harris, who is co-sponsoring Sanders’s Medicare-for-all bill in the Senate, recently had to clarify that she does not support abolishing private insurance.
Asked by a reporter whether Harris has been clear in her position on private insurance, Biden grinned and said, “I’ll let you guys make that judgment.”
Sanders’s aides say a core part of their strategy is emphasizing that the senator from Vermont has spent decades advocating for ideas that have only recently come into vogue with other Democrats. In his speech this week, Sanders intends to “confront the Democratic opponents of Medicare-for-all and directly challenge the insurance and drug industry,” according to his campaign.
Over the weekend, Sanders was just as eager to single out Biden as Biden was to name him.
“Here are the facts. Under Medicare-for-all, over a four-year period, we will transition to a system in which Medicare is expanded to cover every man, woman, and child in the country,” Sanders said in a Saturday statement responding to Biden. He added, “It is preposterous to argue that as we expand Medicare-for-all that people with cancer and other illnesses will not get the care that they need.”
When it comes to the Affordable Care Act, 46 percent of the public hold favorable views of the law while 40 percent hold unfavorable views, a major improvement from several years ago, according to a recent Kaiser Family Foundation poll.

Joe Biden proposes radical leftist health-care plan

by Paul Waldman - Washington Post - July 15, 2019

The 2020 Democratic presidential primary campaign is in many ways an argument between liberals and moderates over the path the Democratic Party should take, and on no issue has that argument been more intense than health care. Joe Biden has now released his health care plan, and while he’s presenting it as a rebuke of the more liberal candidates, in fact it represents a significant move to the left.
That’s not how he’s talking about it. The video Biden put out with the release of his plan was a direct attack on other Democrats for their crazy liberal ideas and their betrayal of Barack Obama. Here’s part of what he said:
“I understand the appeal of Medicare For All. But folks supporting it should be clear that it means getting rid of Obamacare. I’m not for that ... I knew the Republicans would do everything in their power to repeal Obamacare. They still are. But I’m surprised that so many Democrats are running on getting rid of it.”
Now let’s look at what Biden actually proposes. Here are the basics:
  • Create a public option “like Medicare” that would be open to anyone, including those who currently have insurance through their employer.
  • In Republican states that refused to expand Medicaid, allow all eligible people to get the new public option for free.
  • Automatically enroll low-income people in Medicaid or the public option when they interact with the government.
  • Increase ACA subsidies to make insurance more affordable.
  • Force drug companies to negotiate prices with Medicare.
There’s more in there on drug prices, abortion coverage, surprise billing and other topics. But overall, this is not just fixing some problems with the ACA; it goes far past it. It’s extremely similar to the Medicare For America Act introduced by Reps. Rosa L. DeLauro (D-Conn.) and Jan Schakowsky (D-Ill.).
If you are an advocate of single-payer, you’ll find this too much of a compromise. But that shouldn’t obscure the fact that it’s a much more liberal plan than the ACA, which Biden is talking about as though it’s sacrosanct.
That’s the important historical context: In 2009 when the ACA was being debated, a plan like this one would have been considered almost radically leftist. There were still some liberals who would have preferred a single-payer plan to the ACA, but in that moment, what those on the left wanted was to include a public option, a Medicare- or Medicaid-like program that would be offered on the exchanges and compete with private insurers.
The history of the rise and fall of the public option is a bit complicated. But what it came down to is that support for it among moderate Democrats began to bleed, and the White House made clear it wasn’t all that important to them. Sen. Joe Lieberman (I-Conn.), who had become consumed with spite for liberals, declared that if a public option was included then he would join the Republican filibuster and kill the entire ACA.
Then and now, a public option was understood by both liberals and conservatives as the camel’s nose under the tent that could eventually lead to single-payer or something like it. And the fact that even Republicans think that’s what would happen demonstrates that they don’t really believe what they say about private insurance being superior to government insurance.
After all, if government insurance was so miserable, no one would choose the option and it would wither away. But if liberals are right, then it will be attractive and affordable, and more and more people will abandon their private plans for the government plan. Market principles will determine the outcome, which is exactly what conservatives are afraid of. They see how much seniors love their Medicare and how popular Medicaid is, and they’re worried the same thing would happen with a public option.
So is it possible that a plan like Biden’s could be a step on the road to single-payer? Not exactly, but over the long term it could wind up being pretty close. If this new public plan worked well, since it’s open to anyone you could see millions of people gravitate toward it. Eventually we’d have three large government insurers (Medicare, Medicaid and Bidencare or whatever it would be called) and private insurers steadily shrinking. At some point liberals would say, “Why don’t we just combine these three into one program that covers everyone, and leave private insurers offering supplemental coverage?”
Then you’d have a system not too dissimilar from the one in France or the one in Canada, both of which combine universal government-sponsored plans with private supplemental plans, and both of which work much better than ours.
I’m not saying there’s no real difference between single-payer and what Biden is proposing; there are important distinctions and a case to be made for the superiority of the former. But Biden, who is presenting himself as the candidate of moderation and incrementalism, wants to go a lot further than Barack Obama did a decade ago.
Which is reason for liberals to feel as if they’re winning the argument.

Why A “Public Option” Isn’t Enough


At one point, the meaning of “Medicare For All” was quite clear. Under Medicare For All, every American, instead of having to navigate the tangled and inefficient marketplace of for-profit health insurance corporations, would simply be enrolled in Medicare. Instead of people paying premiums and copays to an insurance company, they would pay taxes, and those taxes would be used to pay providers. As Dr. Abdul El-Sayed wrote in this magazine, Medicare For All is “single-payer healthcare that would provide cradle-to-grave government-supported healthcare for all Americans.” 
But as Democrats have realized how well the phrase “Medicare For All” polls with voters, its meaning has been deliberately muddied. Most of the Democratic presidential candidates now support something they call “Medicare For All,” but it’s often not clear what they mean by it. Some, when they clarify specifics, make it clear that what they actually want is a “public option,” i.e. a new kind of government insurance plan that you can buy within the structure of the existing healthcare marketplace. Pete Buttigieg says that he believes in “Medicare For All Who Want It.” Presumably, what this would mean in practice is that when you go to to select your insurance plan, one option would be a thing called “Medicare For All,” and you could buy it, through premiums, if you chose it. This is, as Dr. El-Sayed points out, a “rebranding” of the concept, an attempt to present Bernie Sanders’ single payer proposal and Barack Obama’s old abandoned “public option” idea as roughly the same. 
But how do proponents of (actual) Medicare For All respond to the basic arguments made by those proposing “Medicare For All Who Want It”? What Pete Buttigieg and other moderates say is this: Why force people into a government program? Most people are satisfied with their healthcare (though note the huge difference between the 70 percent of Medicare enrollees who say they are satisfied with the cost, and the 51 percent of people with private insurance who are satisfied with cost). Why abolish private insurance? Why not just have insurance companies compete against a government plan in an open marketplace where people can choose? That way, everyone who wants Medicare gets it, while people who are satisfied with their current insurance can keep it. Everyone wins. The implication here is that anyone who supports a full single-payer plan, in which everyone would just be insured under a government program, must be rigidly ideological, wanting to shutter the private insurance industry for no good reason. Why would we do that instead of just providing a new option?
To understand why full “single payer” health insurance is the left’s goal, rather than just “another insurance plan on the marketplace,” it helps first to understand the left’s vision for how healthcare should work. In an ideal world, your healthcare would not be something you have to think about very much. If you got sick, you would choose a doctor’s office and make an appointment. You would go to that appointment and see the doctor. Then you would leave. You would not have to apply for insurance, not have to pay bills. And this would be the case no matter who you were or how much money you made. In Britain, this is what you do already. As U.K. Current Affairs contributor Aisling McCrea has explained, the NHS makes healthcare easy. “Insurance” isn’t a part of it at all: Your relationship is between you and your doctor, not you and your doctor and your doctor’s hospital’s billing department and your insurance company. Leftists dream of making healthcare as easy as possible to receive and universally accessible to all regardless of how much money they have. 
Private health insurance is an unnecessary part of the healthcare system. Insurance companies are middlemen, and insurance just exists to make sure that providers get paid. It was our government’s own choice to encourage the proliferation of private insurance, through laws like the Health Maintenance Organization Act of 1973. It was the federal government that subsidized private insurance companies and encouraged employers to use them. Other countries didn’t build this kind of healthcare system, for two reasons:
  1. It doesn’t cover everyone.
  2. It creates a bloated, inefficient insurance bureaucracy.
Our government has always been playing catch-up trying to get more people covered. It’s created employer subsidies, Medicaid, CHIP, and the Obamacare exchanges in a desperate bid to get this system to do its job, and despite decades of piecemeal healthcare reforms 13.7 percent of Americans remain without health insurance and millions more have inadequate coverage. Offering to let Americans “buy-in” to Medicare keeps Americans paying premiums, and as long as Americans must personally pay premiums to receive healthcare there are going to be some people who can’t or won’t pay those premiums and go without. It turns Medicare-For-All into a publicly run HMO. Maintaining an employer-sponsored health insurance system means remaining in a situation where large numbers of people go through a period of being uninsured each year, because when you lose your job you lose your insurance. (Currently 1 in 4 Americans go through an uninsured period each year.) Single payer advocates ask the question: “Why have a nightmarish tangle of public and private options, varying by state, with people moving on and off all the time? Why not just pay for healthcare with taxes, cover everyone, and make it free at the point of use?” 
Not only will a public option fail to cover everyone, it will do nothing to restrain the growth of healthcare costs. Single payer systems control costs by giving the health service a monopoly on access to patients, preventing providers from exploiting desperate patients for profit. If instead there are a large number of insurance companies, providers can play those insurance companies off each other. Right now, we have a two-tier system, in which the best doctors and hospitals refuse to provide coverage unless your insurer offers them exorbitantly high rents. To support that cost while still making a profit, your insurer has to subject you to higher premiums, higher co-pays, and higher deductibles. Poor Americans with poor-quality insurance are stuck with providers who don’t provide high enough quality care to make these demands. The best providers keep charging ever higher rents, and the gap between the care they offer and the care the poor receive just keeps growing. Poor Americans are now seeing a decline in life expectancy, in part because they cannot afford to buy insurance that would give them access to the best doctors and hospitals. Costs balloon for rich Americans while the quality of care stagnates for the poor.
The bloat doesn’t just come from providers. Because insurance works on a profit incentive, the insurance companies must extract rents as well. So the patient is paying to ensure not only that their doctor or hospital is highly-compensated, but that the insurance company generates profit too. Each insurance company has its own managers—its own CEO, its own human resources department, and so on. We have to pay all of these people, and because there are so many private insurance companies, there are so many middle managers to pay. (Barack Obama once bizarrely critiqued single payer by saying it would eliminate millions of jobs in the insurance bureaucracy, implying that we should keep admittedly pointless jobs and gouge patients as a make-work program.) 
These duplicate bureaucracies are expensive to maintain and do nothing to improve the quality of care. The providers make them compete to offer higher compensation, and you pay for it. Getting rid of these middle men makes the system far more efficient. We now spend 17 percent of GDP on healthcare. Britain spends 10 percent, and British people can expect to live two years longer. (Though in order to achieve a full cost-effective British system, we’d have to socialize medicine rather than just socializing insurance.) People do not associate government with efficiency, but when it comes to moving money from one place to another—which, after all, is all an insurance company does—it can be quite good, and it makes far more sense to have government handle healthcare payments than to leave it to companies with a direct financial incentive to deny treatment. 
Private insurance is inconvenient, inefficient, and continues to leave large numbers of Americans with inadequate insurance or no insurance at all. The Affordable Care Act shored up this system by funnelling more public money into subsidies for private insurance. Now these Democratic candidates are proposing to make a new insurance company, call it “Medicare,” and charge you premiums to use it. That doesn’t get rid of the problem of wasteful duplicative bureaucracies, and will guarantee that some people remain uninsured.  It was the federal government’s decision to build this bizarre, burdensome system. Nothing about private health care is natural or inevitable. It doesn’t have to be like this. 
And yet: Democratic presidential contenders seem reluctant to call this system what it is, and stand behind a comprehensive replacement. It’s not just Buttigieg. Candidates like Elizabeth Warren and Kamala Harris claim there are “many paths” to Medicare-For-All. In addition to Bernie Sanders’ bill, they’ve quietly signed onto some of the “buy-in” bills circulating through congress. Elizabeth Warren says she has a plan for everything, but there’s no Medicare-For-All plan on her website. (A plan for everything except healthcare, as Tim Higginbotham put it in Jacobin.) When asked at a town hall about it, she said:
When we talk about Medicare for All, there are a lot of different pathways…Some folks are talking about “Let’s start lowering the age. Maybe bring it down to 60, 55, 50″…Some people say “Do it the other way. Let’s bring it up, from, uh, everybody under 30 gets covered by Medicare.” Others say “Let employers be able to buy into the Medicare plans.” Others say “Let’s let employees buy into the Medicare plans.” For me, what’s key is we get everybody at the table on this…I’ve also co-sponsored other bills including expanding Medicaid as another approach that we use.
It’s a waffling answer that tells us little about Warren’s vision for healthcare—beyond her willingness to count the public option “buy-in” bills as “pathways” to Medicare-For-All. Yet Warren also came out at the Democratic debate for getting rid of private insurance. With no actual plan, it’s hard to know quite what she’s advocating. The Harris campaign does something similar. Harris has co-sponsored multiple buy-in bills, including Jeff Merkely’s and even Michael Bennett’s. Asked about Harris’ stance on Medicare-For-All, Harris’ press secretary said:
Medicare-for-all is the plan that she believes will solve the problem and get all Americans covered. Period…She has co-sponsored other pieces of legislation that she sees as a path to getting us there, but this is the plan she is running on.
A single payer system requires a lot of political commitment, because it means going up against the insurance companies and the ritzy providers and telling them they can’t screw us over anymore. They can’t deny us coverage, extract heavy rents, and keep us on the phone forever. If a Democratic candidate doesn’t see a meaningful difference between a public option and single payer, if that candidate sees these things as two different “paths” to the same place, that candidate cannot be trusted to put an end to this madness. They are offering just one more piecemeal reform to prop up a failing system—not a true overhaul.
Single payer healthcare is a tried and tested system, and it isn’t radical. Trying to cobble together “universal” coverage from a patchwork of giant for-profit bureaucracies and government insurance products is senseless. “Eliminating private insurance” rather than “adding choice” may sound unnecessarily sweeping. But private insurance just gets in the way of efficiently paying healthcare providers and covering everybody. Medicare-For-All makes sense, and we shouldn’t let it be watered down.

Records Show Medicare Advantage Plans Overbill Taxpayers By Billions Annually

by Fred Schulte - Kaiser Health News - July 15, 2019


Health insurers that treat millions of seniors have overcharged Medicare by nearly $30 billion over the past three years alone, but federal officials say they are moving ahead with long-delayed plans to recoup at least part of the money.
Officials have known for years that some Medicare Advantage plans overbill the government by exaggerating how sick their patients are or by charging Medicare for treating serious medical conditions they cannot prove their patients have.
Getting refunds from the health plans has proved daunting, however. Officials with the Centers for Medicare & Medicaid Services repeatedly have postponed or backed off efforts to crack down on billing abuses and mistakes by the increasingly popular Medicare Advantage health plans offered by private health insurers under contract with Medicare. Today, such plans treat more than 22 million seniors — more than 1 in 3 people on Medicare.
Now CMS is trying again, proposing a series of enhanced audits tailored to claw back $1 billion in Medicare Advantage overpayments by 2020 — just a tenth of what it estimates the plans overcharge the government in a given year.
At the same time, the Department of Health and Human Services Inspector General's Office has launched a separate nationwide round of Medicare Advantage audits.
As in past years, such scrutiny faces an onslaught of criticism from the insurance industry, which argues the CMS audits especially are technically unsound and unfair and could jeopardize medical services for seniors.
America's Health Insurance Plans, an industry trade group, blasted the CMS audit design when details emerged last fall, calling it "fatally flawed."
Insurer Cigna Corp. warned in a May financial filing: "If adopted in its current form, [the audits] could have a detrimental impact" on all Medicare Advantage plans and "affect the ability of plans to deliver high quality care."
But former Sen. Claire McCaskill, a Missouri Democrat who now works as a political analyst, says officials must move past powerful lobbying efforts. The officials must hold health insurers accountable, McCaskill says, and demand refunds for "inappropriate" billings.
"There are a lot of things that could cause Medicare to go broke," she says. "This would be one of the contributing factors. Ten billion dollars a year is real money."
Catching overbilling with a wider net
In the overpayment dispute, health plans want CMS to scale back, if not kill off, an enhanced audit tool that, for the first time, could force insurers to cough up millions in improper payments they've received.
For more than a decade, audits have been little more than an irritant to insurers, because most plans go years without being chosen for review and often pay only a few hundred thousand dollars in refunds as a consequence. When auditors uncover errors in the medical records of patients the insurers were paid to treat, CMS has simply required a rebate for those patients for just the year audited — relatively small sums for plans with thousands of members.
The latest CMS proposal would raise those stakes enormously by extrapolating error rates found in a random sample of 200 patients to the plan's full membership — a technique expected to trigger many multimillion-dollar penalties. Though controversial, extrapolation is common in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has successfully challenged the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.
"The public has a substantial interest in the recoupment of millions of dollars of public money improperly paid to health insurers," CMS wrote in a Federal Register notice late last year announcing its renewed attempt at using extrapolation.
Penalties in limbo
In a written response to our questions, CMS officials said the agency has already conducted 90 of those enhanced audits for payments made in 2011, 2012 and 2013 — and expects to collect $650 million in extrapolated penalties as a result.
Though that figure reflects only a minute percentage of actual losses to taxpayers from overpayments, it would be a huge escalation for CMS. Previous Medicare Advantage audits have recouped a total of about $14 million — far less than it cost to conduct them, federal records show.
Though CMS has disclosed the names of the health plans in the crossfire, it has not yet told them how much each owes, officials said. CMS declined to say when, or if, they would make the results public.
This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 plans annually.
This spring, CMS announced it would extend until the end of August the audit proposal's public comment period, which was supposed to end in April. That could be a signal the agency might be looking more closely at industry objections.
Health care industry consultant Jessica Smith says CMS might be taking additional time to make sure the audit protocol can pass muster.
"Once they have their ducks in a row," she says, "CMS will come back hard at the health plans. There is so much money tied to this."
But Sean Creighton, a former senior CMS official who now advises the industry for health care consultant Avalere Health, says payment error rates have been dropping because many health plans "are trying as hard as they can to become compliant."
Still, audits are continuing to find mistakes. The first HHS inspector general audit, released in late April, found that Missouri-based Essence Healthcare Inc. had failed to justify fees for dozens of patients it had treated for strokes or depression. Essence denied any wrongdoing but agreed it should refund $158,904 in overcharges for those patients and ferret out any other errors.
Essence also faces a pending whistleblower suit filed by Charles Rasmussen, a Branson, Mo., doctor who alleges the health plan illegally boosted profits by overstating the severity of patients' medical conditions. Essence has called the allegations "wholly without merit" and "baseless."
Essence started as a St. Louis physician group, then grew into a broader holding company in 2007, backed by prominent Silicon Valley venture capitalist John Doerr, with his brother Thomas Doerr, a St. Louis doctor and software designer. Neither would comment for this story.
How we got here
CMS uses a billing formula called a "risk score" to pay for each Medicare Advantage member. The formula pays higher rates for sicker patients than for people in good health.
Congress approved risk scoring in 2003 to ensure that health plans did not shy away from taking sick patients who could incur higher-than-usual costs from hospitals and other medical facilities. But some insurers quickly found ways to boost risk scores — and their revenues.
In 2007, after several years of running Medicare Advantage as what one CMS official dubbed an "honor system," the agency launched "Risk Adjustment Data Validation" audits. The idea was to cut down on the undeserved payments that cost CMS nearly $30 billion over the past three years.
The audits of 37 health plans revealed that, on average, auditors could confirm just 60% of the more than 20,000 medical conditions CMS had paid the plans to treat.
Extra payments to plans that had claimed some of its diabetic patients had complications, such problems with eyes or kidneys, were reduced or invalidated in nearly half the cases. The overpayments exceeded $10,000 a year for more than 150 patients, though health plans disputed some of the findings.
But CMS kept the findings under wraps until the Center for Public Integrity, an investigative journalism group, sued the agency under the Freedom of Information Act to make those results public.
Despite the alarming findings, CMS conducted no audits for payments made during 2008, 2009 and 2010 as they faced industry backlash over CMS' authority to conduct them, and the threat of extrapolated repayments. Records released through the FOIA lawsuit show some inside the agency also worried that health plans would abandon the Medicare Advantage program if CMS pressed them too hard.
CMS officials resumed the audits for 2011 and expected to finish them and assess penalties by the end of 2016. That has yet to happen, amid the continuing protests from the industry. Insurers want CMS to adjust downward any extrapolated penalties to account for coding errors that exist in standard Medicare. CMS stands behind its method — at least for now.
At a minimum, argues AHIP, the health insurers association, CMS should back off extrapolation for the 90 audits for 2011-13 and apply it for 2014 and onward. Should the agency agree, CMS would write off more than half a billion dollars that could be recovered for the U.S. Treasury.

We need to get greed out of the American health care system

by Cathleen London - Bangor Daily News - July 15, 2019

Americans will not see single payer healthcare (Medicare for All or another iteration) any time soon due to greed. Too many people profit off the hard labor of clinicians, particularly of physicians. No, it is not physicians raking in the large paychecks, for that you will have to look to chief executive officers of insurance companies, hospitals, pharmaceutical companies, device manufacturers and healthcare systems. The profiteers. These are not the people delivering the care.
Physicians gave their power away decades ago, and our organizations did nothing to protect us. In fact, the larger organizations helped create the systems we now have. The only people benefitting are the executives and stockholders. Don’t expect it to improve anytime soon.
The way physicians are taught is not conducive to changing the system. Our focus is the patient, the disease process — we cannot dirty ourselves with profit and loss, or cost structures. We naively invited the business people in to do that work for us. They gleefully took over.
We have not learned. While the rest of the industrialized world enjoys universal healthcare and does not worry about how to pay for care when they are ill, Americans go broke. Physicians are treated as commodities and squeezed harder and harder as they break. Physicians are centered on empathy and compassion and capitalism has taken every advantage.
Fewer independent physician practices now exist, which is detrimental to patients (and costs). Reimbursement rates continue to decline with no recourse, which puts physicians in untenable positions: stop taking insurance plans, become an employee, retire, change careers, or find additional income. This is true insanity. With at least 11 years training for each physician this is also an incredible waste of talent and resources.
Now we have mid-level practitioners being churned out by online schools, which is not a replacement for physicians nor the answer to the increasing shortage of physicians. Mid-level practitioners, such as nurse practitioners and physician assistants order more tests, refer to more specialists clogging the pipeline for necessary care, and increasing costs. Where midlevels practice without supervision, care is often stunningly inadequate resulting in complications of chronic medical conditions that are otherwise preventable.
As long as we continue to elect politicians who are turning America into an oligarchy, our system will worsen. American medicine is but a symptom of the greater illness. The founders of the United States envisioned a Federalist Republic. They put in protections against the corruption humans are prone to. Despite this, we are witnessing our own downfall. We are watching as these checks and balances fail.
So yes, I am painting a depressing, realistic picture. Until we as a nation hold politicians accountable for representing everyone nothing will change. Unless physicians take medicine back the spiral continues. There are some small starts: direct primary care (physician run) is one answer to the catastrophe that has become American medicine, but the trajectory is worsening before improvement. Despite the fact that the majority of Americans would favor a single-payer system such as Medicare for All, we do not elect representation that will enact these proposals. Change takes action. Right now we have inertia.
Is this the end of America as we know it? Has capitalism failed all but a few? Are we witnessing the fall of the Republic? Time will tell. I do think things will get worse, particularly for our patients. Treatments will become harder to afford, not because those delivering the care are being paid better, but because money is diverted to those that have learned to work the system the best. American exceptionalism indeed.
Cathleen London of Milbridge is a family medicine physician.

President Trump Withdraws Plan to Eliminate Drug Price Rebates

by Katie Thomas - NYT - July 11, 2019

The Trump administration has abandoned a centerpiece of its efforts to address high drug prices, backing away from requiring some discounts to be passed directly to consumers under Medicare that could have lowered their out-of-pocket costs.
President Trump had announced the proposal with great fanfare in January as part of the administration’s efforts to deal with the rising costs of prescription drugs, which have fueled public outrage. But the decision to kill the proposal is the second time this week that Mr. Trump’s drug-pricing initiatives have failed. On Monday, a federal judge threw out a rule that would have required pharmaceutical companies to list the price of their drugs in television advertisements.
In a statement Thursday, Judd Deere, a spokesman for the White House, said, “Based on careful analysis and thorough consideration, the president has decided to withdraw the rebate rule.”
The rebate rule had long met resistance from within the White House, where fiscal conservatives had balked at the potential cost. The rule was expected to raise drug-plan premiums for all Medicare beneficiaries, and in May, the nonpartisan Congressional Budget Office concluded that the rule, if adopted, would cost taxpayers $177 billion within 10 years.
The administration and leading members of Congress have been discussing some other legislative proposals, including negotiating directly with companies to set caps on some drug prices. The president also announced last week that he would issue an executive order that might somehow connect prices in the United States to those charged by companies in overseas markets, but the details remained unclear.
“President Trump will consider using any and all tools to ensure that prescription drug costs will continue to decline,” Mr. Deere added.
The news, reported earlier by the news outlet Axios, also dealt a blow to the drug industry. It had strongly backed the measure and tried to blame pharmacy benefit managers for rising prices.
The rule would have essentially done away with after-the-fact rebates that drug companies pay to the private companies that operate Medicare’s Part D drug plans, and instead required that any discounts be passed to consumers at the pharmacy counter. Medicare beneficiaries with high drug costs often have to pay a drug’s list price, or a percentage of it, during certain phases of their coverage. They were required to do so even though, in many cases, the companies operating the plans were collecting rebates on the same drug.
The rule had been opposed by the insurers and pharmacy benefit managers who operate Medicare’s drug plans because they said they used the rebates to pressure drug companies to keep their prices low, and used the savings to keep premiums low for all Medicare beneficiaries. But the drug industry has been campaigning for years on the idea that it is unfair for insurers to keep the rebates when consumers are paying the list price through high deductibles.
Alex M. Azar II, the secretary of health and human services, had been a strong proponent of the proposed rule, which he said addressed one of the key reasons the market for drugs is broken.
In a statement, Caitlin Oakley, a spokeswoman for Mr. Azar, said he and Mr. Trump were working together on a range of other drug-pricing proposals. “Secretary Azar is fighting alongside President Trump to lower prescription drug costs and protect America’s seniors,” she said.