Editor's Note -
The following article is an example of the validity of the maxim in capitalism - especially the type of capitalism practiced in the US, there is no such thing as too much profitability.
After bringing about significant corruption of the American health care system, medical corporations are enthusiastically working toward bringing about the same end in the rest of the world's wealth nations.
It's America's gift to the world.
-SPC
US Empire Seizes UK’s National Health Service
It is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete, write Stewart Player and Bob Gill.
by Stewart Player and Bob Gill - Consortium News - December 6, 2021
One of the recent roles of the Parliamentary Healthcare Committee has been to reassure the British public that any claims regarding the ‘Americanization’ of the National Health Service (NHS) were wildly overstated, “creating a climate that risks blocking the joining up of services in the interests of patients.”
In fact, the penetration of the healthcare system by the giant U.S. insurer UnitedHealth reveals the opposite to be true, with the full extent of its influence capable of surprising even seasoned NHS watchers.
The Health and Care Bill making its way through official channels simply reinforces this, with the bill’s centerpiece, the 42 regional-scale Integrated Care Systems (ICSs), aimed at bringing together GPs, hospitals, mental healthcare and council services. It is being effectively designed and fast-tracked by the private UnitedHealth.
The U.S. healthcare system is of course a thing of nightmares. Insurance payments extract almost half the income of an average family, in return for which the nation consistently ranks last for access, equity, and outcomes of care in periodic studies by the Commonwealth Fund.
Not content with employer — or individual-based customers — giant insurers now see as much as 50 percent of their revenues coming from federally-funded services, with studies from Texas revealing the greatest profits within the privatized Medicaid system resulting from denying care to medically fragile children and the severely disabled.
Fraud, scandal, bloated executive salaries and minimal care constitute the norm, yet, owing to the state-capital symbiosis that defines the U.S., the cyclical clamor for reform only sees the industry emerge stronger every time.
This was nowhere more evident than the Affordable Care Act (ACA) of 2010 – also known as Obamacare. Less one thinks this is a digression, it is arguable that one can’t understand the position of the British NHS without also understanding the ACA.
According to BusinessWeek, the leading role in ensuring that ‘reform’ doesn’t happened and that ACA proved a bonanza for health insurers was played by the largest of them, UnitedHealth.
While superficially progressive, those newly insured under Obamacare were all channelled either to subsidized marketplaces or to privatized Medicaid to the extent that within a few years these programs had become the main artery of corporate profits.
The Role of Simon Stevens
Serving as point man in the process was the Briton Simon Stevens. Newly promoted as UnitedHealth’s vice-president, he was also charged with leading the company’s “strategic positioning for national health reform.” The company was nothing if not forward thinking when it also appointed him head of UnitedHealth’s Global Health Division.
With capital’s position secure in the heartland, United began to think of further expansion. In his new role, Stevens first helped set up in September 2011 the Alliance for Healthcare Competitiveness, a high-level lobby group with the aim of deregulating trade laws and forcing other nations to open up their health systems to U.S. for-profit insurers, hospitals, pharmaceutical firms, IT companies and other investor-owned firms.
However, it makes little sense to open up national systems unless these conform to standardized templates, and within the year, Stevens was acting as project steward within the World Economic Forum’s (WEF) project on sustainable health systems.
Advocating new care models – though in effect rebranded U.S. Health Maintenance Organizations (HMOs) – the WEF envisaged a climate where “health schemes and insurance markets boom as people seek to cover their health costs,” while governments “focus on regulating large integrated health providers in a complex expanding global marketplace.”
It only remained for Stevens to return to Britain – “my heart is in the NHS and in U.K. public services,” he said – and in October 2013 he was duly appointed as chief executive of NHS England. Since then he has pursued to the letter the aims of the World Economic Forum and U.S. capital’s.
These include the Five Year Forward View, the New Care Models Programme, the Sustainability and Transformation Partnerships, and, ultimately, the 42 Integrated Care Systems.
A Mixed Economy of Care
In the process, UnitedHealth’s influence has extended across the board. Take commissioning of NHS patient care, for example. Under the terms of the 2012 Health Act, this was to be led by general practitioners but few family doctors had a clue (why should they?) and those that were involved were in it for the extra income and to rubber-stamp decisions made by the commissioning ‘support’ market. (The health care act removed responsibility since 1948 for running the NHS from the health secretary to clinical commissioning groups (CCG), providing an entry for private insurers.)
Serving as chair of the Commissioning Support Industry Group from May 2013, and also providing its secretariat, was UnitedHealth. The group also involved U.S. consultancies, KPMG, McKinsey, EY and PWC. UnitedHealth paid for an annual trip for “senior-level executives from across the U.K. health system” to find out how the company operates in the U.S. and to “explore their applicability in the U.K.”
Since then, this has meant amassing major contracts not only in commissioning support, but also in clinical governance, communications, human resources and workforce development, medicines management, and in implementing Personal Health Budgets.
Groomed By US Capital
As well as bankrolling the largest primary care network, Modality, it has also meant a near-monopoly in data analytics for United, particularly those relating to population health management and the risk stratification of patient cohorts – all exercises in assessing insurance risks and their subsequent costing as the system moves to a mixed economy of care.
But most importantly it has meant United playing the lead role in both defining and fast-tracking ICSs as they await formal legal status. Launched by NHS England in January 2018, the Optum Alliance – consisting of United and PwC – delivered a “major capabilities building programme” to “facilitate the move to whole system working” for the most advanced ICSs.
This included those in Birmingham, Warwickshire, Northumbria, West Yorkshire, Devon, Dorset, and Cumbria, and involved developing capabilities in care redesign – including “radical transformation of outpatient services” and developing primary care networks – financial management, effective leadership, integrated contracting, governance and delivery, as well as building sustainable, value-based, strategies.
For the program, UnitedHealth fielded its most senior partners and directors, all of whom were “experienced leaders in complex business systems.” Under the lead of ICS and clinical commissioning groups, hospital CEOs, finance officers, and local authority chief executives, worked alongside the Optum Alliance and NHS England. But as the director of commissioning for the West Midlands, Alison Tonge, pointed out, it was “UnitedHealth and PwC, who led the sessions.”
As such, despite the talk in policy circles of emerging leaders being brave, innovative, and capable of “high learning agility within new healthcare ecosystems,” it would instead appear they are dutifully being groomed by U.S. capital. Indeed, it is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete.
The Harm Caused
The Health and Care Bill will essentially provide legislative lock-in for the changes already embedded throughout the NHS. Patients will be denied care to generate profits for the ICS, over which their family physician or hospital specialist will have no influence, while the growing unmet patient need will have to be serviced either through out-of-pocket payments, top-up private insurance, or not at all.
The inevitable harm and suffering endured by patients without the money to pay for treatment will affect their families, carers, clinicians and society as a whole. Healthcare professionals working in this two-tier system will themselves be exploited, made to work beyond the competence, offered perverse incentives to act against the interests of patients to generate profits and in doing so fundamentally betraying the healing relationship.
The NHS will, in the immediate future, resemble ‘Medicare Advantage’ or ‘Medicaid Managed Care’, a basic, publicly funded, privately controlled and delivered corporate cash cow repurposed to make profit, though in time the full range of the organizational options found in the U.S. will follow.
All this will increase the total cost of healthcare, deliver less, harm thousands, enrich foreign corporations and destroy what was once Britain’s national pride.
Stewart Player is a public policy analyst and co-author (with Professor Colin Leys) of The Plot Against the NHS (Merlin, 2011).
Dr. Bob Gill is a GP and producer of the feature length documentary The Great NHS Heist.
https://consortiumnews.com/2021/12/06/us-empire-seizes-uks-national-health-service/
An Obscure Agency Is Threatening to Hand Medicare Over to Wall Street
by Anna Malinow - Truthout - December 3, 2021
In the face of massive support for Medicare for All and the failure of the U.S.’s for-profit health care system, the inevitable fall of the medical-industrial complex can be predicted, if not with precision, with certainty. Everyone is aware of the impending demise, none more so than those in charge of the for-profit health care system and their supporters in Congress, as evidenced by the frenetic activity at the Centers for Medicare and Medicaid Services (CMS) to transfer the traditional Medicare program to the insurance industry as fast as humanly possible. Given this urgency, physicians representing Physicians for a National Health Program delivered a petition signed by 13,000 individuals, including 1,500 physicians, to Health and Human Services Secretary Xavier Becerra this week demanding the end to the privatization of Medicare.
Privatization, the transfer of a public good to private, for-profit entities, is already true for over 40 percent of Medicare in the form of Medicare Advantage, private insurance plans that have been persistently and pervasively overpaid by Medicare for decades. As Kip Sullivan recently described in “Single Payer Health Care Financing,” this fraud has been going on for decades.
In 1995, the U.S. General Accounting Office (GAO) warned Congress that Medicare was overpaying Health Maintenance Organizations (HMOs), the precursors to Medicare Advantage plans, by 6 to 28 percent compared to what it would have paid had all those HMO enrollees remained in traditional Medicare because most HMOs benefited from “favorable selection,” meaning, healthier patients enrolled in HMOs. In 1999, the GAO again warned Congress that Medicare spent more on beneficiaries enrolled in HMOs than it would have had those beneficiaries been enrolled in traditional Medicare. The following year, the GAO told Congress that it was largely excess Medicare payments to HMOs, not their efficiencies, that allowed plans to attract large numbers of beneficiaries, again exceeding costs expected under the traditional program, adding billions to Medicare spending.
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Twenty-six years later, in its 2021 report to Congress, the Medicare Payment Advisory Commission wrote, “The Commission estimates that Medicare currently spends 4 percent more for beneficiaries enrolled in MA [Medicare Advantage] than it spends for similar enrollees in traditional fee-for-service (FFS) Medicare.” This low number is difficult to square with the profit that insurance companies are making and the extra benefits that they offer. What has been clear to Congress for decades, is that Medicare Advantage, which inserts a middleman to “manage” care between CMS and doctors and hospitals, costs more than traditional Medicare, which does not require a middleman between the senior and the provider. From 1972 to 2004, overpayment by Medicare to HMOs was the rule and due mostly to favorable selection. After 2004, overpayment persisted for Medicare Advantage plans (formerly known as Medicare + Choice) for two reasons: favorable selection (“cherry picking,” or selecting healthy patients, as well as “lemon dropping,” or getting rid of sick patients, perfected by HMOs) and upcoding.
What is upcoding? When a doctor bills the insurance company or Medicare for a patient, the doctor uses a diagnosis code. For example, a patient who is seen for pneumonia will be billed with the diagnosis code for pneumonia. But what if instead of just billing for pneumonia, the physician also coded for shortness of breath, hypoxia (low oxygen level), productive cough and exposure to tuberculosis, some of which might or might not be accurate, but could certainly be present in someone with pneumonia? This would be upcoding and would be considered fraud, but in the Medicare Advantage world, upcoding is known as risk-score gaming, and it is perfectly legal.
Risk-score gaming is how Medicare Advantage has been drawing serious overpayments since its full implementation in 2006. Medicare Advantage does this by submitting diagnosis codes that create more CMS Hierarchical Condition Categories (HCCs) for each patient. For example, a 76-year-old female with obesity, type 2 diabetes, major depression and congestive heart failure has an HCC risk score of 1.03. For this patient, CMS pays a Medicare Advantage plan that does not upcode $9,000.
If however, the Medicare Advantage plan upcodes — same patient, same medical conditions but more codes: morbid obesity instead of obesity, diabetes with retinopathy instead of diabetes; a mild, single episode of major depression instead of unspecified major depression; chronic obstructive lung disease instead of asthma and a stage 3 ulcer instead of ulcer — her risk score jumps to 3.63, and CMS pays the Medicare Advantage plan for the same patient $32,000. The plan reaps obscene profits, some of which goes to marketing, some of which goes to improve benefits driving up the number of new members, but most of which go back into profits, all the while draining the Medicare trust fund, driving up Part B premiums (monthly payments made by beneficiaries to Medicare) and diverting taxpayer funds from other social services.
For each 0.1 increase in risk score at current enrollment levels, there are $15 billion in overpayments ($13 billion from CMS, and $2 billion from Part B beneficiaries) and the Medicare Advantage plan takes $3.5 billion in profits. Risk-score gaming is the business model for Medicare Advantage and creates a major transfer of wealth to Medicare Advantage from taxpayers and traditional Medicare recipients.
In addition to greater costs to the federal government, Medicare Advantage plans deny care for enrollees, create cost-related problems for enrollees, limit specialized care due to narrow networks (especially at the end-of-life), have worse health outcomes (including higher mortality), and unenroll high-cost beneficiaries (“lemon drop”) who are in poor health.
All evidence points against using the multibillion-dollar health insurance industry to improve outcomes and save money. But evidence is no match for profit. In 2019, the Medicare budget approached $800 billion, and by 2026, it is projected to be $1.35 trillion. This amount of taxpayer money keeps capitalists up at night, especially the medical-industrial complex types, scheming up ways to grab some for themselves. Lucky for these capitalists, CMS is continuing its march towards privatization, or what is known in the parlance of health economists, “de-risking” all of Medicare, meaning eliminating the risk of providing health insurance to seniors by having someone else bear the risk. But the truth is the exact opposite: These overpayments are allowing the insurance industry to pretend they bear risk when in fact it’s the taxpayer who is bearing risk.
There is much profit to be gained by “bearing the risk” for Medicare through favorable selection and upcoding, as evidenced by the outsized profits for insurers in Medicare Advantage compared to margins in the group or individual market. There should be little surprise, then, that the industry is chomping at the bit to “bear the risk,” that is, be overpaid to insure the remaining 60 percent of seniors who have deliberately chosen not to enroll in Medicare Advantage, those that are safely (or so they thought) enrolled in traditional Medicare.
But safe they are not, and every enrollee in traditional Medicare should take note: A program known as the Global and Professional Direct Contracting model in a little-known government agency known as the Center for Medicare and Medicaid Innovation (“The Innovation Center”) is already moving them, without their knowledge or consent, to “risk-bearing,” for-profit middlemen known as Direct Contracting Entities (DCEs). The goal: to end what’s left of traditional Medicare.
The Innovation Center was created under the Affordable Care Act (ACA) in 2010 with a mandate to test “innovative” payment and service delivery models for Medicare that would decrease costs, and if not improve, at least not worsen care. The ACA gave full authority to the Innovation Center to scale up any model it deemed fit, to all of Medicare without congressional approval. In the past 10 years, 54 models have been developed, 50 of which failed and all of which continue to use market-driven models of care. Not one model has been developed to test out single-payer, which actually would decrease costs and save lives. The latest demonstration project, created in the waning days of the Trump administration and greenlighted by the Biden administration, is the DCE model, which is being rolled out to traditional, fee-for-service Medicare beneficiaries without congressional approval or anyone’s vote.
What is a Direct Contracting Entity? Simply put, it is a “risk-bearing,” for-profit middleman to manage health care for traditional Medicare beneficiaries, just like Medicare Advantage plans are for seniors who have signed up for Medicare Advantage plans. The difference is that while 26 million seniors have voluntarily signed up for a middleman when they chose Medicare Advantage, the 38 million seniors in traditional Medicare have not.
How do you get seniors who have specifically chosen traditional Medicare to switch to a non-traditional Medicare-Advantage-like plan with a mysterious name like “Direct Contracting Entity”? You don’t tell them! You lure their primary care providers to participate in a DCE by promising the doctors much better Medicare reimbursement rates and more time with their patients, and once the doctors sign up with a DCE, all their patients are automatically “aligned” by CMS with the DCE the doctor has chosen. The DCE sends patients a letter they are likely not going to read or understand, and presto! Millions of seniors previously on traditional Medicare now belong to a DCE. That’s how DCEs leverage and monetize the doctor-patient relationship for the profit of corporations.
DCE middlemen accept capitated payments for seniors in traditional Medicare just like Medicare Advantage plans, “cherry pick and lemon drop,” deny care, upcode, spend as little as 60 percent on health care for beneficiaries (compared to Medicare Advantage’s 85 percent), and keep the rest as profit. The playbook is an old one, and it works.
There are 53 DCEs in 38 states and Washington, D.C., mostly owned by for-profit, private equity firms, investor-owned primary care practices, Accountable Care Organizations (a network of doctors and hospitals that is jointly accountable for the health of a group of Medicare patients and that receives financial incentives from Medicare to save money on patient care while meeting certain quality metrics) and Medicare Advantage plans. Many DCEs are owned by publicly traded corporations straight out of Wall Street. These are the corporations that will potentially manage the care of up to 30 million seniors who thought they were free of insurance companies. Instead, their health will be weighed against profit. And in a market-driven, for-profit health care system, the bottom line always wins.
But the most important question still remains: Why the urgency to “de-risk” (privatize) Medicare, no matter the cost? Enter Liz Fowler, architect behind the ACA, an industry darling who ensured health insurance companies would reap billions every year under the ACA, the new director of the Innovation Center brought in by the Biden administration to oversee the full privatization of Medicare. Industry giants and Washington insiders can read the writing on the wall as well as anyone else. They are acutely aware that a majority of Americans say it is the government’s responsibility to provide health care for all. They know that a pandemic has shined a light on the inefficiencies, inequities and indifference of our health care system. They know that Americans died in greater numbers and at increased rates compared to countries with universal health care systems in place. In the face of this inevitability, what would the medical-industrial complex and Congress do? Sell off Medicare, and fast, before Americans actually get Medicare for All.
Health and Human Services Secretary Becerra, a supporter of Medicare for All, and CMS Administrator Chiquita Brooks-Lasure have the authority to terminate the Direct Contracting model program. Congress has the power to hold hearings on the Innovation Center and pass legislation to provide congressional oversight to the Center’s pilot programs. The Innovation Center has put a hold on new DCE applications, to the consternation of industry, but all signs point to the continuation of using DCEs to privatize traditional Medicare. The Innovation Center will put a pretty bow around DCEs and talk about “equitable outcomes” and “person-centered care” but we should not be fooled: The end of Medicare is near. It is up to us to demand DCEs, not Medicare, be ended.
https://truthout.org/articles/an-obscure-agency-is-threatening-to-hand-medicare-over-to-wall-street/
Democrats’ Bill Would Go Far Toward ‘Patching the Holes’ in Health Coverage
Taken together, the provisions in the social policy bill represent the biggest step toward universal coverage since the passage of the Affordable Care Act.
Reed Abelson, Sarah Kliff, Margot Sanger-Katz and
WASHINGTON — Of all the “bitter disappointments” he had as president, Harry Truman once wrote, the “one that has troubled me most, in a personal way,” was the failure to enact a national program that would assure all Americans “a full measure of opportunity to achieve and enjoy good health.”
More than 75 years after Truman first proposed universal coverage, Democrats are still chasing his dream. If President Biden’s social policy bill becomes law, they will make major strides toward fulfilling it.
An estimated 3.4 million Americans would gain health insurance as a result of the legislation, which passed the House last month but faces a tough road in the 50-50 Senate. Senator Chuck Schumer of New York, the majority leader, said Tuesday that his goal is to have it pass before Christmas.
The bill would expand health care access for children, make insurance more affordable for working-age adults and improve Medicare benefits for the disabled and older Americans. Separately, its health provisions are a “piecemeal of incremental changes,” said Caroline Pearson, a senior vice president for health care at NORC at the University of Chicago, a nonpartisan research organization.
But taken together, these policies represent the biggest step toward universal coverage since the passage of the Affordable Care Act in 2010.
“This is a moment of extraordinary opportunity for improving health policy and improving the health coverage that people get,” said Stan Dorn, director of the National Center for Coverage Innovation at the advocacy group Families USA.
House Democrats, facing near-unanimous opposition from Republicans and pushback from more centrist members of their own party, failed to include some of the splashy health proposals that were discussed early in the negotiations over the package.
Medicare will add hearing coverage, but not a vision or dental benefit. The government will not gain the ability to bargain down the prices of hundreds of prescription drugs, though it will be able to lower the prices for 20 each year in the Medicare program.
If the measure passes, the United States will retain its patchwork system, where people obtain different health coverage depending on where they live, what they earn, where they work and how old they are.
Even so, Ms. Pearson said, the legislation “is one of the biggest steps toward patching the holes” in the system.
As a group, the health care provisions will cost $330 billion over the next decade and come with compensating health savings of $325 billion, according to an analysis of Congressional Budget Office data by the Committee for a Responsible Federal Budget. But that balance is slightly misleading: The parts that save money are designed as permanent, while several new coverage provisions would expire after 2025.
Even with the changes, the Congressional Budget Office estimates that more than 27 million people would remain uninsured, including many undocumented immigrants, whom the bill does not assist. Many of the remaining uninsured would be eligible for expanded Obamacare subsidies or Medicaid, but are not expected to sign up.
Here are some of the programs — and people — the legislation would affect.
Providing Medicaid to New Mothers for a Year
Christina Ruiz had plenty to worry about when she gave birth two months early, in August 2020.
Her infant daughter had to spend five weeks in the neonatal intensive care unit while Ms. Ruiz, 34, dealt with her own postpartum complications. She developed high blood pressure, and the stitches on her C-section incision began to unravel three weeks after delivery.
One thing Ms. Ruiz did not have to worry about: medical bills. She had enrolled in Medicaid early in her pregnancy, and it fully covered both her and her daughter’s costs.
But while Medicaid has become a major source of health coverage during pregnancy — about 40 percent of the country’s babies are born to mothers who receive the coverage — it ends 60 days after delivery. Researchers say this is an especially problematic time for women to lose health insurance, when they are still at high risk of postpartum complications.
The United States has the highest maternal mortality rate in the developed world, and about 12 percent of such deaths happen more than six weeks after delivery. A lack of insurance may play a role.
The social policy bill would provide Medicaid to new mothers for a full year after delivery instead of just two months, allowing more time to address postpartum medical issues that can surface later.
The Century Foundation estimates the provision would extend coverage to about one million women over the next decade.
The legislation would also expand coverage for children, by permanently funding the Children’s Health Insurance Program, which covers 10 million low- and middle-income children, and by making it harder for children to lose Medicaid coverage because of paperwork errors or fluctuating family income.
The postpartum coverage could help Ms. Ruiz, who is now pregnant with her second child.“It makes all the difference,” she said, “not having to worry about health care bills.”
Erasing the ‘Coverage Gap’ for Poor Adults
Tim Floyd of Guntown, Miss., was working construction jobs in 2012 when he noticed numbness in his foot. It was neuropathy, a sign of diabetes. But he was uninsured and could not afford a doctor visit.
“If you are having to pay $60 out of pocket, you go, ‘Well, it’s not exactly right, but it’s not stopping me from doing anything, so I’m going to just keep on pushing,’” Mr. Floyd, 45, explained.
The neuropathy kept Mr. Floyd from feeling a rock that had slipped into his boot while working. The rock caused a sore on his right foot. A doctor treated the wound, but it festered for five years. By the time Mr. Floyd learned he had diabetic ulcers, the infection had spread to his bones, leaving him no choice but to have his leg amputated from the knee down.
He lives in one of 12 states where Republicans have refused to expand Medicaid under the Affordable Care Act, citing the cost, of which states would eventually pay 10 percent. The social policy bill would close the so-called Medicaid coverage gap by offering an estimated 2.2 million low-income adults like Mr. Floyd free private insurance — but only for four years.
Unable to work after the loss of his leg, Mr. Floyd turned to singing and playing drums for a living, performing gigs with his cover band, Proximity Rule. But just as he was learning to walk with a prosthesis, he said, he noticed a lump in his neck. He waited a year, then saw a doctor, who told him he had Hodgkin’s lymphoma, a type of blood cancer.
Mr. Floyd said a social worker at North Mississippi Medical Center helped arrange for free treatments — surgery, chemotherapy and radiation. “The preventive care,” he said, “is what I couldn’t get.”
Providing Premium Subsidies to Middle-Class Americans
Jill Swenson and her husband were raising buffalo in upstate New York in 2009, when he had a recurrence of skin cancer. The couple had no health insurance, a factor that Ms. Swenson says contributed to her husband’s suicide. The Affordable Care Act made coverage accessible to her again in 2014, and she has had it every year since, but it was still a stretch.
She now lives in Appleton, Wis., where she is a self-employed editor and literary agent. She earned around $45,000 last year, and paid more than $300 a month for her insurance. During the pandemic, Congress has temporarily increased the premium subsidies provided under the health law — a $200-a-month discount that Ms. Swenson, 63, said has allowed her to buy birthday gifts for her niece and nephew, keep up with rising grocery costs, and pay utility bills and her mortgage.
“There’s nothing to cut,” she said. “It’s not like I’m living high on the hog.”
The temporary boost in subsidies extends up and down the income spectrum, lowering the cost of insurance for almost everyone who buys it through the Obamacare marketplaces. The social policy bill would keep it in place until the end of 2025.
The change was a response to a widespread concern that the Affordable Care Act had not, in fact, made insurance affordable enough for many Americans. More than half of people who were uninsured last year qualified for premium subsidies or Medicaid, according to an analysis from the Kaiser Family Foundation. Since the new subsidies were introduced, along with a big advertising push, an additional 2.8 million people have enrolled in coverage.
Expanding Home Care, and Raising Wages for Those Who Provide It
After she recovered from cancer, Shara Clark decided to become a home health aide in June as a way to give back. “When you go through a medical scare such as I did, you develop empathy for others,” she said.
Employed by an agency in Charlotte, N.C., she works 25 to 40 hours a week, helping clients get dressed, make a meal or get around.
But Ms. Clark, 41, also has two part-time jobs. “Because I’m only getting paid $10 an hour, that does not match the cost of living,” she said.
The $150 billion in the spending bill for home and community-based services has two goals. It would allow more elderly and disabled people on Medicaid to qualify for subsidized care in their homes or at community programs, helping them avoid moving to a nursing home. There are currently an estimated 800,000 people on waiting lists for these services.
But the money is also supposed to go toward raising wages for home care workers like Ms. Clark.
Home care workers make an average of under $14 an hour, or less than $30,000 a year, according to a new study from the Economic Policy Institute, a liberal group. Most of the workers are women, and many are of color.
“Wages have to go up if services are going to go up,” said Ai-jen Poo, the executive director of the National Domestic Workers Alliance, an advocacy group. “Those two goals are absolutely interdependent.”
Capping How Much Medicare Recipients Spend on Drugs
Mariah Forster Olson’s treatment for childhood cancer left her with a range of health problems, and a long list of prescriptions. Ms. Forster Olson, 42, takes 30 prescription drugs every month and about 50 pills a day, requiring weekly trips to the pharmacy. Her Medicare coverage makes a big difference, but still leaves her with thousands of dollars in bills.
There is currently no limit on how much Medicare recipients can be expected to pay out of pocket for their drugs, a situation that leaves some who take expensive medicines with annual bills of $15,000 or more. But for the 2.5 million beneficiaries who spend more than $2,000 a year on their drugs, Medicare would pay all their costs above that amount under the bill.
The legislation would also cap out-of-pocket costs for insulin at $35 a month. That change alone could affect the more than three million Medicare beneficiaries who take the drug to manage their diabetes.
Ms. Forster Olson, of La Crosse, Wis., who qualifies for Medicare because she is disabled, said her drug costs could be as high as $7,000 next year without a change. “A cap of $2,000 would be amazing,” she said.
Hearing Aids for Older Americans
Anne Madison, a retired computer systems engineer in Baltimore, started losing her hearing in her 50s. Now 71, she cannot afford hearing aids, which can cost as much as $5,000. Medicare will not pay for them.
“I can’t whip out the Mastercard,” she said. “If I put that much money on it, I’ll be in trouble for the rest of my life.”
Nearly two-thirds of Americans older than 70 have hearing loss, but fewer than 20 percent of them use hearing aids, said Dr. Frank Lin, an ear, nose and throat surgeon at Johns Hopkins School of Medicine.
When Congress created Medicare in 1965, hearing aids were in their nascence, Dr. Lin said, and hearing loss was “not seen as anything remotely important.” Today medical professionals know better; beyond being “arguably the leading risk factor for dementia,” hearing loss can lead to social isolation and depression, Dr. Lin said.
But while Medicare will pay for an audiologist to diagnose it, that is where most coverage stops.
The House-passed bill would add coverage of hearing services to Medicare beginning in 2023. Audiology services, including counseling for hearing aids, would be reimbursed, and the devices themselves would be covered for people with “profound or severe hearing loss.”
Ms. Madison, of Baltimore, is addressing her hearing problem another way for now: She enrolled in a study at Johns Hopkins that evaluated over-the-counter hearing amplifiers that cost about $150. She is now able to attend meetings and church services, and has pleased neighbors by turning down the volume on her television.
And, she said, “it was amazing to me to be able to hear my little grandchildren.”
https://www.nytimes.com/2021/12/01/us/build-back-better-act-health-coverage.html
Genetic Risks for Cancer Should Not Mean Financial Hardship
Leah Pierson and
The Piersons are sisters with a family history of breast cancer.
Tens of millions of Americans have received genetic tests illuminating their risk of disease, and a majority of adults in the United States say they would be interested in getting tested. When we each turned 20, we sought genetic testing to learn whether we had inherited our mother’s BRCA mutation, which significantly increases the risk of breast, ovarian and other cancers. We each had a 50 percent chance of inheriting it, but our fates diverged: One of us, Emma, has the mutation, and the other, Leah, does not.
The results of this genetic coin toss mean that Leah is financially well protected by her health insurance, while Emma and countless other people who have a high-risk genetic mutation are not. It’s an inequity that the United States should rectify through state and federal legislation.
The Affordable Care Act requires most private health insurers to cover, at no cost to the patient, genetic testing for people at high risk of having certain harmful mutations. But more than a decade after the passage of the bill, people with genetic mutations remain unprotected in two important ways.
First, insurers don’t have to cover genetic testing for all harmful mutations. Private insurers are required to cover genetic testing only for BRCA mutations in high-risk women. (Both of our tests were covered.) They do not have to cover testing for other common genetic conditions, like Lynch syndrome, the most common cause of hereditary colon cancer. It’s unfair to require coverage for only a small subset of patients with high-risk mutations when scientists know of many others and continue to discover new ones.
A second problem is that insurers are not required to cover the recommended follow-up care for many patients who carry a high-risk mutation. For instance, both the American Cancer Society and the National Comprehensive Cancer Network recommend that young women at high genetic risk for breast cancer undergo annual magnetic resonance imaging scans. But the A.C.A. does not require private insurers to cover the cost of those scans.
As a result, while Leah is legally entitled to receive her medically recommended breast cancer screenings for free, insurers do not have to cover the earlier and more frequent screenings that Emma requires. (Medicare and Medicaid, which operate under different rules from private insurers, can cover more genetic testing, but some patients can still encounter insufficient coverage.)
A similar problem plagues people with colon cancer mutations who require early colonoscopies, like those with Lynch syndrome. And people with rarer mutations may face even greater barriers to having necessary care paid for by their insurers.
This isn’t just unfair; it’s also not cost-effective. Catching cancer early through medically recommended screenings can save the health care system the huge costs of treating late-stage cancers.
Health insurers sometimes choose to cover some of these services, but even in these cases, high deductibles and co-payments can render this care unaffordable.
The practical consequences are predictable and devastating. Breast M.R.I.s can cost thousands of dollars before coverage, and only a quarter of high-risk women have M.R.I.s fully covered. As a result, women may forgo this potentially lifesaving screening. Research suggests that even tiny increases in out-of-pocket costs — as small as $10 for a drug — may lead patients to avoid treatments with large benefits.
Even patients who do seek care may find that their options are limited: If a risk-reducing mastectomy will be fully paid for, but yearly breast M.R.I.s will not, young women may feel pressured to get mastectomies over expensive scans. Some women may avoid genetic testing out of fear that a positive test could increase health costs.
Making sure people at high genetic risk for cancer are guaranteed full coverage — at no cost to them — if they seek genetic testing or preventive screenings requires legislation. The A.C.A. bases its coverage requirements on recommendations from the U.S. Preventive Services Task Force, which grades preventive medical services, like cancer screenings, based on how likely they are to be beneficial.
But these recommendations focus on people at average risk of cancer, and generally omit people with genetic mutations. For example, the recommendations for colorectal cancer and breast cancer screening specifically say they are not designed for people with high-risk mutations. Private insurers are thus not required to cover the extra screenings these patients need.
The federal government should require insurers to cover the screenings necessary for people at increased genetic risk, at no cost to the patient. Failing federal legislation, several states have put forth promising solutions. New York recently passed a law requiring insurers to cover the cost of breast M.R.I.s when medically necessary, and Massachusetts is considering similar legislation.
Americans who carry high-risk mutations represent a large and vulnerable population, but their predicament is, in many ways, only the beginning. As genetic testing expands, doctors will gain the ability to make increasingly sophisticated risk predictions for larger groups of people. Health care policy must keep pace with the science. Health insurers should not be able to treat sisters differently on the basis of a genetic coin toss.
Leah Pierson (@leah_pierson) is a medical student at Harvard and a Ph.D. student at the Harvard T.H. Chan School of Public Health. Emma Pierson (@2plus2make5) is an assistant professor of computer science at Cornell Tech and Technion-Israel Institute of Technology and an assistant professor of population health sciences at Weill Cornell Medical College.
https://www.nytimes.com/2021/11/26/opinion/genetic-risks-cancer.html?referringSource=articleShare
Public Health Experts Slam 'Grossly Inadequate,' Industry-Friendly Covid Test Reimbursement Scheme
Despite the White House's claim that its new Covid-19 strategy, unveiled Thursday, is "pulling out all the stops" to get the pandemic under control, public health experts and progressives are slamming the Biden administration for its "grossly inadequate" plan to push health insurance companies to reimburse people for rapid over-the-counter tests—a plan that will do nothing to encourage frequent testing, critics said.
"This is where the U.S. is an international outlier. Making testing free is clearly a good idea."
President Joe Biden announced that people with private insurance will be required to submit receipts to their insurance companies to be reimbursed for tests that currently cost between $14 and $34. Retroactive reimbursement for tests people have already taken prior to the plan being released will not be permitted; the administration said it plans to release more guidelines and restrictions for the plan by January 15.
For the 28 million Americans who don't have private health insurance, the administration said it would distribute 50 million free tests—covering fewer than two per person—through community health centers and rural clinics in addition to 20,000 free testing sites across the country—a proposal that is "still not adequate" for uninsured Americans and "creates a two-tier level of access to tests," according to researcher and physician Dr. Adam Gaffney.
The plan puts the U.S. far behind other wealthy countries, several of which have for months offered free Covid-19 tests to residents as a way of helping to stop the spread of the virus, with governments taking on the burden of purchasing the tests and then distributing them to the public.
"This is where the U.S. is an international outlier," Martin McKee, a professor of European public health at the London School of Hygiene and Tropical Medicine, told the Washington Post. "Making testing free is clearly a good idea."
Britain and Singapore both deliver free rapid tests to people's homes, and Germany began offering all residents free rapid tests in March. People in India can access Covid-19 tests for about $3 each, making the frequent testing needed for people to keep track of their health status more feasible for many than it is in the United States.
Instead, wrote Matt Stoller of the American Economic Liberties Project, Americans' rapid tests will "come with more bureaucracy."
In addition to "making people hassle with insurance" companies, as Rep. Alexandria Ocasio-Cortez (D-N.Y.) said, the insurance reimbursement scheme could lead manufacturers to charge more for tests, making them less accessible for many.
"If the consumer is thinking, 'I will get reimbursed,' they won't really care about the price," Ge Bai, a professor of health policy at the Johns Hopkins Bloomberg School of Public Health, told the New York Times Thursday.
The administration did not limit how much healthcare providers could charge for Covid-19 tests when it required insurers to cover tests at doctor's offices and testing sites—allowing some providers to bill thousands of dollars for tests. The White House has yet to say whether it will cap the amount that insurance companies will have to cover for rapid over-the-counter tests.
"We need this administration to be courageous. This is not it at all," said Dr. Uché Blackstock, founder of Advancing Health Equity. "Rapid at-home tests and high-quality masks should be free."
Scientist Dr. Lucky Tran accused the White House of "pandering to insurance companies and the market," while health researcher and physician Dr. Eric Reinhart said Biden's attempt to address a public health crisis within the confines of the for-profit health insurance industry would be "a disaster."
Immunologist Dr. Rick Bright, who issued early warnings about the pandemic to the Trump administration in January 2020, pointed out that demand for free Covid-19 tests is high; a free at-home test program introduced in New Hampshire and Washington state quickly ran out of supplies late last month.
"People want to get tested, but tests are too expensive," said Bright. "[The] federal government should make testing affordable for everyone."
Ocasio-Cortez suggested the insurance reimbursement plan offers the latest argument in favor of Medicare for All, including #M4A in her tweet about the issue.
"We can do better," tweeted the congresswoman.
Doctors and Hospitals Make Late Bid to Change Surprise Billing Ban
A lawsuit says the Biden administration’s faulty interpretation of the law will harm medical providers.
by Margot Sanger-Katz - NYT - December 9, 2021
Three weeks before a new ban on surprise medical billing is set to start, hospital and doctor groups have filed suit to block part of it.
The suit, from the American Medical Association, the American Hospital Association and a handful of individual hospitals and providers, argues that regulators in the Biden administration have misread the law’s language — and that their faulty interpretation will harm medical providers.
The lawsuit does not seek to gut the law’s consumer protections, but could influence contract negotiations between insurers and health care providers. If successful, the lawsuit could influence which doctors and hospitals choose to go in network with insurers, and could lead to higher insurance premiums.
Other parties, including consumer groups, employers, insurance companies and members of Congress who wrote the law, have supported the regulation.
The bipartisan law, which passed after years of study and negotiation in Congress, is meant to prevent patients from getting a surprise bill from a doctor who doesn’t take their insurance when they visit a hospital that does accept it. It addresses a significant problem in the health system: Nearly 20 percent of patients who visit an emergency room are treated by an out-of-network provider, according to several studies. High shares of patients are also vulnerable to such bills when they are treated by anesthesiologists, pathologists or radiologists whom they did not select.
The legislation, which bans surprise bills starting Jan. 1, prevents such doctors from billing patients directly. When the doctor and the insurance company can’t agree on a fair price, the law establishes an arbitration system in which the parties can seek a decision from a neutral expert.
The law specifies that the arbiter should look to a typical price paid to doctors covered by insurance — the median in-network price. And the arbiter is expected to consider other factors, such as the doctor’s experience, the number of other providers nearby, and the severity of the patient’s illness. In their lawsuit, the medical providers say the Biden administration’s instructions for arbiters lean too heavily on the typical price; they think the arbiter should be free to weigh all of the different factors equally.
“The departments have no authority to discard Congress’s judgment that training and experience are important considerations in determining the appropriate payment rate, even if they disagree with it,” the lawsuit says.
Doctors and hospitals lobbied furiously when Congress was considering the legislation, helping to scuttle an earlier bill that would have required the typical price without allowing an arbitration process. A dark money group funded by large physician practices spent tens of millions of dollars on television ads and direct mail to voters, encouraging them to tell their legislators not to support the bill.
When the final version of the legislation was passed with the arbitration option added, it was applauded by both insurers and medical providers.
As regulators at the Department of Health and Human Services, the Treasury Department and the Department of Labor have worked on the rules, industry lobbying on all the details has continued.
In a comment supporting the regulation, the Business Group on Health, which represents large employers, called the rule “a thoughtful and balanced approach to the interests of the various stakeholders.” In its supportive comments, the American Heart Association said the rule “will produce reliable and consistent results that do not have an inflationary impact on health care costs.”
The Congressional Budget Office noted that the solution was likely to lower payments to doctors who worked in specialties where surprise billing was widespread.
People involved in the fight over surprise billing said they were not surprised about the lawsuit. “There’s a lot of money at stake here, and it’s not at all surprising that the provider groups would sue in order to hold onto some of the payments they are receiving today,” said Matthew Fiedler, a fellow at the Brookings Institution.
According to the lawsuit, the regulation will discourage insurers from reaching agreements with doctors and hospitals, and will instead push them to seek lower payments through routine use of arbitration.
The suit includes affidavits from two hospital executives who say they are confident the regulations will cause insurers to cancel contracts or demand that hospitals lower their fees. The lawsuit asks a court to eliminate the instructions about the weighing of factors. Consumer protections would remain in effect if they won.
Mr. Fiedler offered a contrasting view from the doctors, saying a less predictable arbitration process could lead to fewer clinicians who are in network, as more of them rely on arbiters to settle payment disputes.
Some members of Congress who worked on the legislation have offered similar criticisms of the regulation, saying it was not what they intended when the wrote the bill. But other key authors have endorsed the regulatory approach.
In order to win the suit, the medical providers will need to show that the Biden administration was “arbitrary” or “capricious” in its interpretation of the law or that it lacked statutory authority, a high standard. The language of the legislation says arbiters should consider the various factors, but does not specify how they should be weighed.
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