Friday, January 20, 2023

Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!

The things to remember about “Medicare Advantage” plans is that 1) they are not Medicare, and 2) they may offer little or no advantage. They are a form of private insurance, cost Medicare a lot of money, and in some situations (especially when you are sick) can indeed hurt you.

Let’s get to the first. Medicare was created in 1965 to provide universal health care to senior and disabled people. It was a tremendous victory for those who had fought for decades to have a universal health insurance system in the US. It was also strongly opposed by those who thought their pocketbooks might be hurt, specifically the AMA, as well as other right-wing forces that just opposed everything that might actually help most people (and thus most Great Society, and even New Deal, programs). The supporters never envisioned that Medicare would be the end of the road, especially when, in the same year, Congress passed Medicaid, a federal-state collaborative program that was aimed at helping the poor access health care. They assumed that it would be expanded to finally include all Americans.

Of course, many of the opponents of Medicare didn’t give up either. The AMA, while never contrite, shut up about it after it became clear that rather than hurting physicians’ incomes, Medicare was a bonanza for them, ensuring payment for services had often previously been unable to collect for. Those who hate programs that benefit people, of course, are still around. But the most insidious and dangerous threat is from those who see any government program as a way to make lots of money, especially if it can be privatized without much risk to the private sector investors. This is really how Medicare (and many other public programs) have been most insidiously and effectively attacked -- by privatizing its programs to guarantee lots of money for the profit of the private companies, and largely insulate them from risk.

Enter Medicare Advantage (MA).  MA plans are largely run by insurance companies (and sometimes by venture capital groups) and are called “Part C” of the Medicare program, but they essentially take people out of Medicare and put them in a private managed care program. These companies then get the money that would have gone to the Medicare program (we’ll call it Traditional Medicare, or TM) for you. Plus they get extra money. Why do private companies caring for you under MA get more money than TM allocates for you? Because they do, right. Because the pro-for-profit “caucus” (PFPC) of the Congress, from both parties, wanted to increase the portion of people in Medicare entering MA. So these companies could make more money. And contribute more to the members of the PFPC.

Remember the old phrase “feeding at the government trough”? That is what these companies do, very well. Virtually no public function that is privatized becomes more effective at delivering service, since the amount of profit generated is increased by providing less service. To the extent that it sometimes seems to look better, it is almost always because of 2 things: that the public services were starved for funding in the first place, making them look bad and justifying the call to privatize them, and that private companies’ inefficiency, corruption, and overall bad acting is harder to ferret out than government agencies’.

How do MA plans make more money? In the traditional HMO manner, they limit access to a “panel” of doctors and hospitals. These are not necessarily the worst ones in your area, but they are the ones that the plans have negotiated the best deals with, for which they pay the least. They attract members with some perks like vision care, hearing care, etc., which can be useful if one is generally healthy. And of course, MA plans vary in quality and in performance; some of those covering state employees by contract have performed better possibly because of having a more educated, informed, and influential client base. But this is not always the case; see the example of city workers’ resistance to Mayor Eric Adams of NYC trying to push retirees into MA.  

And do not consider for a moment that the goal of any of these programs is to provide excellent health care: it is to make money. And that they make money is demonstrated by the aggressive marketing that Medicare-eligible people get from these companies, not to mention television advertising. The Commonwealth Fund recently published a piece called “The Role of Marketing in Medicare Beneficiaries’ Coverage Choices”, which describes this in detail. ‘Soaring private plan enrollment has led to a sharp increase in marketing and sales efforts, some misleading and inaccurate.’ It goes on to explain in how MA works and how they market. It also notes that about 1/3 of Medicare beneficiaries used an insurance broker; a boon to that private sector industry as well. MA plans can keep 15% of the money they get for profit and overhead, having to spend only 85% on actually delivering care (which they call the “medical loss ratio”!)

The way that MA plans make money is enrolling lots of people, many of whom are healthy (Wow! Free gym membership!) and don’t cost them much, and then submitting bills that make their patients look like they are as sick as possible thus inflating their bills (called “upcoding”). At best this an effort to maximize revenue from Medicare, which there is no incentive to do in TM. Plus, if they can get certain poor people enrolled, they can collect an additional $350 for each one regardless of whether they actually provide any care! This was implemented with the theoretical idea of increasing equity by incenting the enrollment of poor people, but really has the opposite effect since those folks now have their care restricted when they are sick by the private insurance company, while under TM it would not be. And, of course, they make money by fraudulently overbilling Medicare for billions of dollars, winning the Lown Institute’s 2022 “Shkreli Award” for bad behavior by corporations!


MA is not the only way Medicare is being privatized. As I have written before ("Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022; Direct Contracting Entities: Scamming Medicare and you and bad for your health!, Feb 7, 2022), the Center for Medicare and Medicaid Services Innovation Center (CMMI) implemented Direct-Contracting Entities (DCE), which was renamed REACH as of January 2023 (without any other significant change). REACH has allowed the creation of mostly investor-owned companies that contract with primary care practices (often already owned by corporations, not owned by the doctors) and voilĂ , all of those doctors' patients are in their REACH group, which then gets the money that Medicare would have paid for you. What is really tricky is that, unlike MA, you didn’t have to choose it; they choose for you by contracting with the group (often corporate) that owns your primary care practice! And your doctor may not even know that s/he is in one! You can only get out if you can find another doctor who is not in one – particularly difficult in rural or urban underserved areas where even finding a doctor is hard. Not to mention that REACH is even more lucrative than MA, as it allows the private company to keep 40% of its take as profit and overhead, spending only 60% on patient care!

The effort to privatize Medicare is absolutely the wrong way to go. The way to go is to keep the structure of Traditional Medicare, where anyone can use any doctor or hospital, where there is no profit taken out, and overhead is about 2%. And then increasing its benefits so that it covers 100% (not 80%) of approved charges so people don’t have to get a Supplement Plan, as well as cover dental, vision, hearing, etc. This is affordable, since it could be funded by money now used to generate huge profits for private investors, but could actually be used to improve our healthcare. While we still need to address access in terms of geography and specialty distribution, eliminating the profit motive will make major steps toward access and improved quality.

Then we can have Healthcare for All.


Monday, January 2, 2023

The People's CDC: Getting out accurate information, not what is popular

I think I’ll start with the following message:

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

I’ll say it again later. I think I’ll keep repeating it. It’s good, and nice, to want positive things. There are a lot of things that I want. World peace, for one. A reversal of global warming. An end to world hunger. They are not happening. And, unlike COVID, people could end them if they wanted to, as a group, as a world. COVID is a virus and doesn’t care what we do, but there are things that we can do to decrease its threat to health and life. We mostly know what they are – immunizations, wearing masks. Limiting interpersonal interaction, especially with large groups and groups with people we don’t know. We’ve been doing it for several years.

But we’re tired of it. We don’t want COVID to be around. We don’t want to wear masks, especially those uncomfortable N-95s (i.e., the ones that work best, the ones that protect you from others; most masks only protect others from you). We want to get together with our families, most especially around important events like the holidays, even if we’re not sure if they’re infected, or were vaccinated, or even if we know they haven’t been. Or if they have been exposed by going to places – like school and work – where they are more likely to be exposed. And we want to, some of us, go out like we used to, to movies and museums and clubs. We want to party. We want to go back to what we think of as normal. But…

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

And so we get infected, and maybe do ok. Especially if we have been immunized. Especially if we are relatively young and healthy and not immunocompromised. It’s not fun, but I survived, right? Oh, yeah, Uncle George didn’t. And Cousin Minnie, who had cancer, and my friend Kim, who has diabetes, almost didn’t, they were hospitalized on a ventilator. And yes, I admit it, I got sick after a small Christmas – or Chanukah, or Kwanzaa or New Year’s – party where I thought I knew everyone and they were my ‘pod’ and I was safe. And, yes, a bunch of people got it. So lucky that none of them have been really sick!

You get the point. But the other point is that we want it to be over! We don’t want  to wear masks! We want to get back to normal! And the government, including the CDC, hears you. They want you to be happy. They want you to support their policies so you will vote for them in the next election. So they say things that are more likely what you want to hear. Like most people don’t need to wear masks indoors in most situations (read: you don’t need to wear a mask. People who do are overreacting). Like you are non-infectious after 5 days, and can go back to work, and if you are infectious still, too bad. Like “the pandemic is over”, comment that President Biden made in a television interview, this past September. Hopefully, you are not coming into contact with people who are susceptible and vulnerable. They want you to like them!

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.

To say that “the media is complicit” sound trite, like a bad meme, like what you hear from the right-wing fringe. Whether it is or not might, I suppose, depend upon what you mean by “complicit”, but most of the media certainly reinforces this “it’s gonna be all right!” message. This particularly takes the form of disparaging those who point out danger. Recently, for example, the New York Times ran a piece called “The Last Holdouts”, about those folks who continue to wear masks. It was on page 1 on December 26. However, in the same issue ran another story updated from December 13 titled “It’s Time to Wear a Mask Again, Health Experts Say: A high-quality, well-fitting mask is your best protection against infection from the coronavirus, influenza and R.S.V.”. That, in the print edition, was at the bottom of page D6! What is the message? If you ever found the latter story, you might be convinced, but the main big story was that masks are for sick people, immunocompromised people, paranoid people – not you!

And now the New Yorker magazine has entered the arena with a piece about the “People’s CDC”, a group of physicians, epidemiologists, public health professionals and others who, very concerned about the upbeat “Pollyanna” messages from CDC, have gotten together to try to disseminate accurate, if often unpopular, information. By writer Emma Green, under a head “Annals of Activism”, the title is “The Case for Wearing Masks Forever”. Well, good. But is that title sincere or snarky? Maybe the subhead gives a clue: ‘A ragtag coalition of public-health activists believe that America’s pandemic restrictions are too lax—and they say they have the science to prove it.’ Oh, they’re ‘rag-tag’! Like internet conspiracy folks! Well, no. They are people like

‘Mindy Thompson Fullilove, a professor of urban policy and health at the New School…who has spent her career studying epidemics: first AIDS, then crack, then multidrug-resistant tuberculosis. She has seen how disease can ravage cities, especially in Black and working-class communities. From the beginning, Fullilove was skeptical of how the federal government handled the coronavirus pandemic. But these new recommendations from the C.D.C., she said, were “flying in the face of the science.” Not long after the announcement, she sent an e-mail to a Listserv called The Spirit of 1848, for progressive public-health practitioners. “Can we have a people’s CDC and give people good advice?” she asked. A flurry of responses came back.’

That doesn’t sound negative. But, overall, the tone of the article is snarky and dismissive of the People’s CDC. It is also laced with red-baiting as well as “realism” in the form of comments from former CDC director Tom Frieden. While he praises ‘the organization’s [People’s CDC] guide to self-protection for immunocompromised people, and agreed that some of their recommendations, like universal masking in times of high COVID spread, were good ideas in theory,’ he added

“But is that going to happen? Absolutely not,” he said. The next best thing is to try to get people vaccinated and boosted and to increase access to high-quality masks and Paxlovid. “If you’re giving recommendations that no one’s going to follow, that’s not only nonproductive,” he said. “It’s counterproductive, because that undermines your credibility.”

Let’s do polling and find out what people want to do and recommend that! Of course, if they get sick and die, your credibility could also suffer…

One of the big things the  article sees wrong with People’s CDC, apparently, is its emphasis on collective action and the health of the community, including efforts to protect its most vulnerable members. This, of course, is contrary to the idea that “it’s all about me”. However, despite its tone and basic support for the current “it’s gonna be all right”, the article is worth reading for the perspectives and data-driven information provided by members and supporters of the People’s CDC, who say things like “There’s a struggle going on right now for the soul of public health.”

People’s CDC takes issue with the way that the C.D.C. emphasizes individual choices over collective action. The current CDC director, Rochelle Walensky, has said, “Your health is in your hands.” Well, as much as I wish it were not, and that CDC and Walensky and the rest of the government, federal, state and local, were doing what needs to be done, I guess it is. And if it is you should wear a mask when you’re indoors with others. Preferably an N-95,

COVID is not over. Even if you want it to be. You can still get sick, get hospitalized, and die. People who are more vulnerable are even more likely to. Masks still are protection. Even if you don’t want to wear them.


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