JustCare

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  • Americans are extremely angry about US health care

    Americans are extremely angry about US health care

    The murder of UnitedHealthcare CEO, Brian Thompson, has revealed extraordinary anger among Americans over our health care system. Will Congress finally act to guarantee people access to needed care and prevent insurers from inappropriate delays and denials of care? Likely not.

    Tens of thousands of people on social media reacted unsympathetically to the killing. ““When you shoot one man in the street it’s murder,” one person posted on the social media site X. “When you kill thousands of people in hospitals by taking away their ability to get treatment you’re an entrepreneur.”

    Wendell Potter, a former Cigna exec and whistleblower, explains on CNN how the CEO’s murder happened just ahead of a shareholder and investor meeting of UnitedHealthcare. UnitedHealthcare satisfies its investors through restricting access to care. That’s how UnitedHealthcare maximizes profits.

    Potter explained that “There’s a lot of just pent-up outrage at this company and other companies that are middlemen that are standing between a patient and his or her doctor or hospital.” For their part, Minnesota physicians report excessively high denial rates by UnitedHealthcare.

    As a result of insurance company practices, people are not getting the medically necessary care they need. The casings on the bullet of the gunman who killed Thompson echo the practices of the insurers: “delay” and “deny.”

    According to the Minnesota Star Tribune, United Healthcare also has been accused of relying on a claims process, supported by artificial intelligence, that had a 90% error rate in determining whether a requested treatment was medically necessary.”

    The Star Tribune further reports on UnitedHealthcare’s insanely high denial rates. In 2021, “UnitedHealth’s qualified health plans in Arizona denied almost 39% of in-network claims.” UnitedHealthcare is the largest health insurer in the US. Another 16 smaller insurers had denial rates that were above 30%.

    Only a few days ago, Anthem decided not to go forward with a proposal to limit anesthesia coverage for certain surgeries and other procedures. It appeared to act in response to massive outrage at the policy. Had Anthem moved forward with the proposal, it would have driven up health care costs for Americans and maximized profits for the insurer.

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  • Will the Trump administration support Medicare coverage of Ozempic?

    Will the Trump administration support Medicare coverage of Ozempic?

    Among his final acts as President of the United States, Joe Biden proposed Medicare coverage of Ozempic for obese individuals. It will be up to the Trump administration to decide whether to finalize this proposal or kill it. What would RFK Jr. do about Medicare coverage of Ozempic if he is confirmed as head of the US Department of Health and Human Services posits Jonathan Cohn for The Huffington Post?

    Cohn explains that Medicare coverage of Ozempic would be consequential for millions of people. It would deliver potentially significant benefits to them. At the same time, it could cost the Medicare program a tremendous amount of money.

    Ozempic is a glucagen-like peptide or GLP-1 agonist because it works just like a hormone in our bodies that reduces our blood sugar and desire to eat. GLP-1’s have delivered health benefits since the early 2000’s. They became popular when they could be taken once a week. They are also sometimes referred to as semaglutide.

    Semaglutide–marketed in some cases as Ozempic or Wegovy–treats diabetes, heart disease as well as weight loss. But, it is quite costly, with prices as high as $1,000 a month.

    Today, Medicare only covers semaglutide for people with diabetes and heart disease. By law Medicare covers medically reasonable and necessary treatments for health conditions, with a few exceptions, including weight-loss. The Biden administration is now arguing that when people are found to be obese, it threatens their health, and a semaglutide affords them medically reasonable and necessary treatment.

    If the Trump administration finalizes coverage of semaglutide, the price tag is projected to be around $40 billion over ten years. More than ten percent of the 65 million people with Medicare are obese. But, if the Trump administration does not repeal Biden’s Inflation Reduction Act, which allows for Medicare drug price negotiation, the federal government would have the power to pay a lower price for the drug beginning in 2027.

    RFK Jr. has said that he opposes coverage of semaglutide. He argues that obesity stems from malnutrition. We should be spending taxpayer dollars on healthy meals for Americans, not using it to boost Pharma profits.

    To be clear, the evidence shows that people are obese for a number of reasons, and many of those reasons have nothing to do with healthy eating.

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  • Trump reelected: What happens to health care?

    Trump reelected: What happens to health care?

    With Donald Trump on his way back to the White House, we can be sure that our health care system will change dramatically over the next four years. Sarah Owermohle reports for StatNews on ways in which Trump could restructure US health care.

    As Trump said in his victory speech, Robert F. Kennedy Jr. is likely to be in charge of “mak[ing] America health again.” It’s not at all clear what that means. Americans appeared less focused on health care this election and more focused on the economy. However, health care costs are part of the economy and have always been a large concern for Americans.

    This go round, Trump claims he won’t try to end the Affordable Care Act. He says he simply wants to reduce costs. That could mean lower costs for healthy people and higher costs for people who need care. It could also mean health insurance options that are not comprehensive, for example, insurance that does not cover prescription drugs.

    Tax credits that help people with low incomes afford insurance premiums could not be extended at the close of 2025, when they expire. Republicans in Congress don’t support them.

    Trump says he will not support a law that bans abortion in American. He intends to prevent funding for gender-affirming care and prohibit it for minors entirely. He will protect employers’ right to refuse to cover birth control based on their religion.

    What will Trump do with Medicare? During his last presidency he ultimately decided not to support lower drug prices. Will he try to undo Medicare drug price negotiation for high-cost drugs?

    Both Medicare and Medicaid are on the table. He might try to do away with traditional Medicare. Although Medicare Advantage has cost the Medicare program significantly more than traditional Medicare, Republicans in Congress still look to the corporate insurers offering Medicare Advantage plans to contain costs. Trump left open the possibility that he would cut spending on Medicare and Medicaid. In his first presidency, he gave states permission to put work requirements on some people with Medicaid.

    Trump says he wants a commission to look at the growth of chronic illnesses in America. Who knows what that will lead to. To date, he has not embraced RFK Jr.’s notion that vaccines are responsible for chronic diseases. RFK Jr. will not lead the Department of Health and Human Services, according to a Trump spokesperson, but he still could have significant authority over recommended vaccines.

    On a brighter note, Trump has said he will ensure access and insurance coverage of in vitro fertilization.

    Trump says he supports tax credits to help with the costs of  America’s 53 million plus caregivers. He has yet to offer details as to what that would look like. Health savings accounts, which tend to be of little help to people when they need costly care, is one way he might go.

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  • Kamala Harris announces plan to expand Medicare to cover long-term care at home

    Kamala Harris announces plan to expand Medicare to cover long-term care at home

    Today, Kamala Harris announced her plan to expand Medicare to cover long-term care at home. This would be life-changing for older adults, people with disabilities, and those who love them.

    This plan is paid for by expanding Medicare’s power to negotiate lower drug prices so that Big Pharma stops ripping us off. Older adults get lower drug prices and a new home health benefit.

    Currently, older adults and people with disabilities who need care that family can’t provide are too often warehoused in dehumanizing nursing homes. Often, these nursing homes are owned by private equity corporations who are exploiting patients for profit. Under the Harris plan, older adults and disabled people would have the freedom to stay in their own homes.

    This is a universal benefit, in the grand tradition of Franklin D. Roosevelt and Frances Perkins. Everyone on Medicare would qualify.

    This is a win for everyone in America — except the billionaires.

    [Editor’s note: For the Harris plan to work effectively for people with Medicare, the benefit would be coupled with an out-of-pocket cap in Traditional Medicare, so that people who did not want a big Medicare Advantage insurance corporation coming between them and their treating physician could get the home care they need when they need it in Traditional Medicare. Alternatively, the benefit would be available only directly through the government. Medicare Advantage insurers would not be deciding whether people qualified for the home care benefit and profiting from denying people home care services.

    Today, only wealthy Americans can afford Traditional Medicare because it lacks an out-of-pocket cap and requires people to buy supplemental coverage to protect themselves against financial risk. Lower income Americans are forced to choose among Medicare Advantage plans without the information they need to avoid the bad actors.  Under the current defective Medicare Advantage payment system, health insurers profit from denying care. Consequently, many insurers are engaged in widespread inappropriate delays and denials of care, according to the HHS Office of the Inspector General and many other health policy experts.

    Medicare does cover a limited amount of home health care today, but it is very hard to get more than a dozen hours of care each week and the benefit is only available to people who are homebound and need daily skilled nursing services or therapy services on an intermittent basis. People in Medicare Advantage plans get less home health care than people in Traditional Medicare]

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  • People with Medicare increasingly going without private supplemental coverage

    People with Medicare increasingly going without private supplemental coverage

    A new report from the US Census Bureau reveals that an increasing number of people with Medicare are going without private supplemental coverage. While the report does not look into why this is the case, more people with Medicare are opting for Medicare Advantage plans, which don’t allow people to have supplemental coverage. In addition, more people in Traditional Medicare are not buying supplemental coverage, either because it is not available to them or it is unaffordable.

    While the Census Bureau does not explore the risks of people with Medicare not having supplemental coverage, the risks are significant. Without supplemental coverage, out-of-pocket costs in the form of deductibles and copays are often unaffordable. People of color, people with low incomes and people in poor health are particularly at risk.

    People enrolling in Medicare Advantage plans often mistakenly believe they are saving money over enrolling in traditional Medicare, when in fact they can easily spend a lot more on their care in Medicare Advantage than in traditional Medicare with supplemental coverage. Comprehensive Medicare supplemental coverage costs around $2,500 a year, while out of pocket costs in Medicare Advantage for people who need a lot of care can easily be $5,000 a year for in-network care alone. Unfortunately, we can’t predict when we will be diagnosed with a costly condition or be hit by a car and need costly care.

    People in traditional Medicare without supplemental coverage pay about 16 percent of the cost of their care; they have no out-of-pocket cap. That can be prohibitively expensive for most people, leading them to opt not to get care. Traditional Medicare should have an out-of-pocket cap.

    The maximum out-of-pocket cap in Medicare Advantage can be as high as $8,850 this year for in-network services. Beyond this out-of-pocket limit, because Medicare Advantage plans too often inappropriately delay or deny care or have restricted networks that will not allow you to see the doctors you need to see, you can be liable for the full cost of care you need. So, whether you are in traditional Medicare or a Medicare Advantage plan, out-of-pocket costs can be thousands of dollars without supplemental coverage. Most people with Medicare delay or forgo care when their costs are unaffordable.

    The Census Bureau report shows that in the five years between 2017 and 2022, the rate of people with Medicare with supplemental coverage fell more than 8 percent from 47.9 percent to 39.6 percent.

    Medicare should have far lower out-of-pocket costs, both to promote health equity and to ensure every older adult and person with a disability has access to the care they need, regardless of their ability to pay for it.

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  • Medicare Advantage enrollees denied post-acute care get better protections

    Medicare Advantage enrollees denied post-acute care get better protections

    The Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, just issued a final rule designed to protect Medicare Advantage enrollees whose Medicare Advantage plans deny them needed care and help ensure providers are paid for the care they deliver. Josh Henreckson reports for McKnight’s on how the rule improves the process for appealing Medicare Advantage denials for rehab and skilled nursing services after hospitalization.

    So that you’re up to speed: Insurers selling Medicare Advantage plans have repeatedly been found to inappropriately delay and deny necessary skilled nursing and rehabilitation care post-hospitalization. People in traditional Medicare get this care. Medicare covers up to 100 days of skilled nursing and rehab services for people who need daily skilled services and have been hospitalized for at least three days in the 30 days prior to admission to a facility.

    People enrolled in Medicare Advantage plans struggle to get the rehab and skilled nursing care they need, not only because their plans deny them coverage but because they are on the hook for the cost of care that their Medicare Advantage plans won’t cover even when they appeal the decision. The CMS final rule ensures that these patients will not be liable for the cost of their treatment if they fail to appeal a denial of coverage while they are in the skilled nursing facility or rehab facility or if  they do not win their appeal. Beginning in June, people in MA plans whose post-acute care is terminated will no longer be liable for the full cost of services after termination.

    People who appeal these Medicare Advantage plan denials of skilled nursing or rehab care win more than eight in ten times. But the vast majority of people do not appeal. Often they do not know they can appeal. Or, they fear having to pay privately for the cost of their care if they do not win on appeal.

    As important, the new CMS rule requires that an independent organization decide fast appeals for people in skilled nursing and rehab facilities. The Quality Improvement Organization and not the Medicare Advantage plans will decide these appeals

    And, if people continue their care after their Medicare Advantage plan terminates their post-acute coverage and do not appeal at that time, they will now have the right to appeal after they leave the skilled nursing or rehab facility.

    The final rule also helps skilled nursing and rehab facilities. They have been struggling because Medicare Advantage plans fail to pay them even when these plans’ have inappropriately denied their patients needed care. Without an independent review agency, there’s no reason for providers to believe that care denials will be overturned; the insurers have no incentive to reverse their original decision.

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  • If you have prediabetes, Medicare can help

    If you have prediabetes, Medicare can help

    If you are over 65, the odds are near 50 percent that you have prediabetes, meaning that your blood sugar levels are above normal, but it’s nothing to worry much about. Prediabetes does not mean that you are likely to get diabetes. But, if you have prediabetes, you should consider taking advantage of Medicare’s Diabetes Prevention Program or rethink your diet and daily activities.

    Why are older adults more inclined to have prediabetes? A lot of older adults have somewhat higher blood-sugar levels than normal because they tend to produce less insulin than younger adults. They also process insulin less efficiently. Learning how to stay healthy with less insulin can be great for your health.

    What to do if you have prediabetes? Prediabetes is associated with a greater risk of heart disease. So, you should focus on being active, keeping a healthy weight and eating healthy foods, particularly more protein, reports Judith Graham for Kaiser Health News. Medicare’s Diabetes Prevention Program is designed to help you do just that.

    Medicare’s Diabetes Prevention Program: Four years ago, Medicare began covering a Diabetes Prevention Program for people with prediabetes. The program offers classes in the community that teach people with Medicare how to eat healthy, lose weight and exercise more. Unfortunately, people do not know about the program or, if they do, most do not enroll.

    The risk of diabetes if you are found to have prediabetes: Some experts believe that you should be screened for prediabetes at 45 and again every three years. An April study by the Centers for Disease Control found that, in one year, just 2,500 out of 50,000 older adults with prediabetes ended up with diabetes. That amounts to a five percent risk of getting diabetes.

    A 2021 study in JAMA Internal Medicine found that fewer than one in eight people with prediabetes ended up with diabetes after six and a half years. That’s less than 12.5 percent of people with prediabetes. Many more of them got their blood-sugar levels under control.

    Risk factors for diabetes: You’re more likely to have diabetes if you are overweight or have a family history of diabetes. Black older adults and people with low incomes are also more at risk of getting diabetes. And, men are more likely than women to have diabetes.

    Should you take metformin? Don’t take metformin, says one endocrinologist, if you have prediabetes. Only take it if you have diabetes and are prescribed it.

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  • Five Proven Interventions for Insomnia

    Five Proven Interventions for Insomnia

    With age, the total amount of time we sleep decreases, and sleep becomes more fragmented. So, we shouldn’t expect the same sleep patterns we had when we were younger. Many people’s body clocks seem to advance, so that they go to sleep earlier and awaken earlier. Most people need about 7-9 hours of sleep each night, though the right amount for any individual leaves them awakening refreshed and allows them to remain alert throughout the day (without resorting to stimulants like caffeine.)

    If insomnia is a problem, the first things to address are medical problems that may be interfering with sleep. These include sleep apnea, restless legs syndrome, gastro-esophageal reflux disease (GERD) or heartburn, heart failure, pain, frequent urination, and medication. Alcohol too interferes with good, restorative sleep.

    Second, while sleeping pills work, they are best used on a short-term basis. Even in the short term, sleeping pills can have side effects, such as impairing your ability to think clearly and leading to falls. In the long-term they can be habit-forming, lose effectiveness, and some may contribute to cognitive decline.

    Third, basic sleep hygiene measures are important for just about everyone; a previous post describes them.

    If sleep continues to be a problem after getting back to these basics, working with a therapist or even on your own on a program of cognitive-behavioral measures specially designed to help with insomnia has proven to be very successful.

    Finally, mindfulness meditation helps with a variety of problems such as anxiety and depression, and has also been shown to be helpful for sleep. A therapist or counselor can guide a patient in learning how to do it, and again there are books and online programs that can be used by do-it-your-selfers. Of course there’s an app for that too; Headspace is a popular one.

    This post was originally published on May 31, 2018.

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  • Does exercise make you hungrier?

    Does exercise make you hungrier?

    Gretchen Reynolds reports for The New York Times on a new study that speaks to the effects of exercise on hunger. As you might expect, you are not likely to lose weight simply by exercising moderately, if you are not otherwise active. But, you are not likely to gain weight either.

    Researchers looked at how moderate exercise affects the appetite of overweight men and women between the ages of 18 and 55 who don’t tend to move their bodies. It found that while they did not eat more afterwards, even when offered “enticing” food, they did eat heartily. In short, exercise did not lead them to eat less.

    The data suggest that when you begin exercising, you are not likely to lose the weight that you think you might, given the calories you burn from exercising. Our bodies do not release our fat easily or quickly. It can take months. Some earlier studies have found that exercise can decrease people’s appetites in the short-term. But others show that exercise can lead people to eat more, to have bigger appetites.

    Differences in study results are to some extent a function of who the participants are. If participants are young and active, the results could easily differ.

    In short, if you’re mildly overweight and take up walking or light weightlifting, you are not likely to lose weight. Study participants burned about 300 calories each time they were active. But, they ate about 1,000 calories at lunch.  Still, you can take heart that exercise should not lead you to eat more and gain weight.

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  • Coronavirus: Older adults more likely to be vaccinated, regardless of party affiliation

    Coronavirus: Older adults more likely to be vaccinated, regardless of party affiliation

    The Delta variant of the novel coronavirus is wreaking havoc in the US because so many Americans remain unvaccinated. Thankfully, 90 percent of older adults have received at least one COVID-19 vaccine. Political affiliation is not driving vaccination decisions for older adults in the same way that it appears to be keeping younger Republicans from getting vaccinated.

    Kaiser Health News reports that nearly 50 million older Americans have been vaccinated. So, even if they are infected with the Delta variant, they are not likely to be hospitalized, much less to die of COVID. That said, those older adults who are not yet vaccinated are taking a huge gamble with their lives.

    Overall, many Republicans have chosen against being vaccinated, putting their lives at risk. But, the majority of older adults, regardless of political party, have been vaccinated. Political party has not affected vaccination rates among older adults significantly.

    Older adults have benefited from being first up for vaccinations and the focus of many COVID vaccination campaigns. They appear to recognize the dangers of not being vaccinated. The data is clear. Four out of five people who have died of COVID-19 are people over 65.

    Still, one in ten older adults still need to be vaccinated. It is doable. Some states have shown the way, doing an especially good job of ensuring older adults are vaccinated. In Vermont, Pennsylvania and Hawaii, the vaccination rate for older adults is 99 percent. West Virginia has the worst rate though far better than the country as a whole, with 78 percent of older adults vaccinated.

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