JustCare

Category: Health and financial security

  • Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Congress could end overpayments to big insurers in Medicare Advantage and save $1 trillion, without gutting Medicaid

    Instead of gutting Medicaid, Congress could save $1 trillion by ending hundreds of billions of dollars in overpayments to corporate health insurers in Medicare Advantage. A new report by Arnold Ventures details how our federal government could effectively end Medicare Advantage and other health care wasteful spending, save as much as $4 trillion, and not touch Medicaid spending.

    The Arnold Venture report spells out 10 ways for Congress to spend less and 10 ways to close tax loopholes that could pay for a permanent extension of the 2017 Tax Cuts and Jobs Act (TCJA). It proposes four smart ways to spend less on health care.

    Arnold Ventures recommends fixing the broken Medicare Advantage payment system that leads to as much as $140 billion a year in overpayments to corporate health insurers. Insurers use a variety of methods to maximize government payments, including “upcoding.” Insurers add diagnosis codes to enrollees’ medical records, which allows them to bill Medicare at higher rates for these enrollees, even when the insurers provide no additional services to these enrollees. The government could adjust down the rate it pays insurers to reduce overpayments significantly. This policy could save as much as $1 trillion over 10 years.

    If Congress ended overpayments to health insurers, the health insurers would claim that the government was “cutting” people’s Medicare benefits. But, the government would still be spending as much on enrollees in Medicare Advantage as in Traditional Medicare. The government would simply be reducing fraud and waste.

    Arnold Ventures recommends “site-neutral payments,” a policy that would require Medicare to pay the same amount for care in a hospital setting as for care in a physician’s office. For reasons that make little sense other than bolstering hospital coffers, today Medicare pays hospitals as much as four times more when a service is performed in a hospital setting. Hospitals have gamed the Medicare payment system by buying physicians’ practices; they can then legally charge the hospital outpatient rate for services, even though the services are identical to what they were before the hospital owned the practices.

    A few years ago, Congress limited the ability of hospitals to continue to game the Medicare payment system through purchases of physician practices. But, Congress grandfathered in the higher rates for hospital outpatient clinics established before the law passed. Ending this grandfathering provision alone would save $30 to $40 billion over ten years.

    Shockingly, the current Medicare payment system still creates an incentive for hospitals to steer patients to get care in a hospital setting, even when the service can be provided at far lower cost in a physicians’ office. Site-neutral payments could save as much as $157 billion over ten years. It would also lower out-of-pocket costs for people with Medicare.

    Arnold Ventures recommends penalizing pharmaceutical companies if they raise the price of their drugs above the rate of inflation for people in the commercial marketplace. The Inflation Reduction Act enacted this policy for Medicare and Medicaid but not for working people. This policy could save the federal government as much as $40 billion over 10 years.

    Arnold Ventures supports requiring Medicaid managed care plans to pay hospitals and nursing homes no more than the Medicare rate.

    Today, states can direct Medicaid managed care plans to pay hospitals and nursing homes at “average commercial rates.” Those rates are far higher than the Medicaid fee-for-service rates. They also incentivize hospitals with monopoly power to increase their rates, which are already twice Medicare rates. Medicaid managed care plans should not be allowed to pay hospitals and nursing homes more than the Medicare rates. This policy would save as much as $120 billion over 10 years.

    Here’s more from Just Care:

  • Why do Americans die younger than people in other wealthy nations?

    Why do Americans die younger than people in other wealthy nations?

    Americans have shorter life expectancies than people in other wealthy nations, even though we spend more on health care than other nations. The Peterson-KFF Health System Tracker looks at why it is that Americans die younger than people outside the US.

    KFF studied mortality rates in the US as well as Austria, Belgium, Canada, France, Germany, Japan, Netherlands, Sweden, Switzerland and the United Kingdom. Americans have a premature death rate of 408 deaths for 100,000 people under 70. The other countries had 228 premature deaths, close to half as many as people in the US.

    Unlike other wealthy nations, which have seen a reduction in the number of their premature deaths, the US has faced an uptick since 2010. Americans had a similar life expectancy as people in peer nations 45 years ago. We saw some increase in life expectancy with scientific advancements, but other countries saw greater increases in life expectancy by 1990. Moreover, peer countries did not see as great a reduction in life expectancy from COVID-19 as the US.

    Heart disease and cancer are the two leading causes of death in each of the countries studied, particularly for older adults. New medicines have reduced the number of premature deaths from heart disease. But, since 2010, Americans have seen an increase in premature deaths from heart disease, while other countries have seen a decrease.

    Americans suffer more from heart disease, chronic respiratory diseases, and chronic kidney diseases, which are collectively responsible for about 105 of the 408 premature deaths. COVID-19 was responsible for 64 of the 408 premature deaths in the US, and substance abuse was responsible for 29 of the premature deaths.

    Today twice as many Americans die of heart disease before the age of 70 than people in peer countries, likely because of more substance abuse and obesity in the US. Moreover, people with chronic heart conditions need ongoing medical care to remain healthy. But, Americans face much larger barriers to care than people in other countries.

    Cancer death rates declined by 40 percent in the US since 1988 for people under 70. And, the US cancer death rates remain comparable to those in peer countries over the last 40 years. Older Americans are less likely to die of cancer than people in peer nations. Some believe that’s because more Americans have died prematurely of other conditions than people in peer nations.

    Younger Americans suffer more from chronic conditions, substance abuse, injuries and communicable diseases than people in peer nations. Fifteen to 49 year olds in the US suffer two and half times more premature deaths than 15-49 year olds in peer nations. The premature death rate for this population in the US has not changed much in the last 45 years. In peer nations, it has dropped by half!

    The US has also seen higher numbers of childhood deaths than other wealthy nations. Over the last 45 years, the number of deaths of 0 to 14 year olds in the US has declined some, but it’s still higher than peer nations, 20 more deaths per 100,000 American kids. Some attribute this difference to racial disparities leading to worse health of babies at birth, more of whom are born premature or with congenital birth defects. In addition, three to four times more American kids died from killings, travel fatalities (we drive bigger cars and have less public transportation) and choking.

    Thankfully, medical advances have reduced death rates a lot. Many fewer people die of neonatal conditions, birth defects and HIV/AIDS. Deaths resulting from heart conditions also have dropped considerably. And, because fewer people smoke, fewer people are dying of cancer and heart disease. But, we are the richest country in the world, and there’s no excuse for our continuing to have shorter life expectancies than people in ever other wealthy country.

    Here’s more from Just Care:

  • Why it’s so hard to find a primary care doctor?

    Why it’s so hard to find a primary care doctor?

    With the medical profession becoming increasingly corporatized and physicians burdened by administrative ordeals and unable to treat patients as they think appropriate, fewer people are becoming physicians, particularly primary care physicians. A new report on the situation in Massachusetts by the Massachusetts Health Policy Commission explains why it’s so hard to find a primary care doctor.

    These days, you can wait a long time to see a primary care doctor, and you are too often forced to switch from one to another. Insurers do not treat continuity of care as a value and limit your coverage to their ever-changing and often restricted network of providers. It’s hard to get an annual check up without a long wait.

    Massachusetts is looking into the shortage of primary care doctors with the goal of increasing their numbers. You need a primary care doctor. The shortage will continue unless government acts.

    Three key reasons for the shortage:

    1. The bulk of primary care doctors in the US are older, averaging 55 years old, and retiring by the time they are 65. Others are just exhausted by their workload and administrative demands on them.
    2. New physicians are less likely to go into primary care because insurers pay little for preventive services; the provider money is in procedures and tests to treat conditions. Moreover, medical school can be very expensive and becoming a specialist allows physicians to pay off their debt more quickly.
    3. Those primary care doctors who continue to practice either end up doing new services to make money or going into concierge medicine, which gives them more time with patients and less administrative hassle.

    What is the value of having a primary care physician? Preventive services help identify diseases early or stop them altogether.

    What is to be done? We need to pay higher rates to primary care physicians and reduce their administrative burdens. As a society, we need to be investing in primary care.

    Here’s more from Just Care:

  • Should AI help with end-of-life decisions?

    Should AI help with end-of-life decisions?

    Artificial intelligence or AI is on the rise. If you haven’t yet tried using AI, check out Perplexity or ChatGPT. It boggles the mind how quickly they can answer your questions about just about anything, including drafting a research paper, writing a poem and explaining health care options. The Harvard Gazette explores the question of whether we should want AI to help patients and health care providers with end-of-life decision-making?

    For sure, AI has become better than some physicians at diagnosing patients’ conditions and arriving at a prognosis. In addition, hospitals and medical clinics use AI to analyze test results. Large-language models now permit AI to advise on patient care. Patients will make the ultimate decision.

    Of course, some patients are not competent enough to guide providers as to their end-of-life choices. And, some situations are fluid, depending upon the patient’s condition or even the time of the day.

    How could AI help a patient at the end of life? AI could explain what patients could expect. It could describe extremely thoroughly possible physical limitations of a diagnosis, pain, possibilities for treatment and more. Its advice would not be emotionally-laden.

    If the patient at the end of life could not speak for himself or herself, AI would have a more objective perspective perhaps than providers or family members about the patient and the patient’s perspective.

    In theory, AI could provide better advice than a physician about a patient’s chance of survival from a particular treatment. That advice would not dictate a particular outcome. AI probably should not be determining what a patient should do. That should happen between patient and doctor.

    When there’s no doctor available, AI could provide some patient care. Could AI deliver care in compassionate ways? How would that affect the patient’s health outcome?

    Here’s more from Just Care:

  • 2025: Tariffs take effect, your costs likely to rise

    2025: Tariffs take effect, your costs likely to rise

    President Trump is making good on his pledge to place high tariffs on goods from China beginning today, February 4. (Tariffs on goods from Mexico and Canada have been postponed for a month, as of now.) The fallout just from the tariffs on China is likely to be bad for your health and financial well-being. Along with the price of gas, cars, and eggs if the tariffs on Canada and Mexico go into effect, prepare now for increases in prescription drug and other health care costs, reports John Wilkerson for StatNews.

    Trump now acknowledges that his tariffs will cost you. Because China delivers us many prescription drug ingredients (Mexico provides us medical devices and Canada supplies gas, eggs and avocados and other produce) it’s far to assume the prices of prescription drugs will increase as well. In fact, we might end up with shortages of generic drugs if their manufacturing cost increases so much that companies can’t profit off their sale.

    In addition, hospital charges could rise. Hospitals use imported gowns, syringes and other supplies. Sometimes CT and X-ray machines are imported. Consequently, people are likely to see still higher health insurance premiums.

    Trump: “WILL THERE BE SOME PAIN? YES, MAYBE (AND MAYBE NOT!). BUT WE WILL MAKE AMERICA GREAT AGAIN, AND IT WILL ALL BE WORTH THE PRICE THAT MUST BE PAID.” Trump suggested that the Canadian tariffs might lead Canada to agree to become a 51st state!

    Even conservative groups are concerned about the effects of the tariffs. The US Chamber of Commerce called the tariffs a mistake. Tariffs on Mexican and Canadian goods will not address immigration or fentanyl issues, as the President has suggested.

    If the Canadian and Mexican tariffs go into effect, Americans should assume those countries will retaliate. Before Trump backed off the tariffs on Canadian goods (yesterday), Trudeau had asked Canadians to boycott American goods, including Kentucky bourbon and Florida orange juice, and avoid vacations in the US.

    Here’s more from Just Care:

  • Government should be spending more on Medicare and Medicaid

    Government should be spending more on Medicare and Medicaid

    A new KFF tracking poll shows that a large majority of Americans–Republicans, Democrats and Independents–support Medicare and Medicaid. And, twice as many Americans believe the government should be spending more on Medicare and Medicaid than believe we should be spending less. Still, Republicans are looking at slashing Medicaid, and possibly cutting Medicare as well.

    Out-of-pocket costs in Medicare are formidable. They keep people from getting care or lead people to delay needed care, compromising their health So, major support for Medicare expansion is not surprising. (It should go hand in hand with ending the waste and fraud in Medicare Advantage, which is costing taxpayers tens of billions of dollars a year, eroding the Medicare Trust Fund and driving up Medicare Part B premiums.)

    There is general agreement among Americans across the political spectrum that we should know a lot more about healthcare prices. But, what people don’t appreciate is that knowing these costs offers them little if any protection. The surgery costs at one hospital might be higher than another, but the anesthesia cost could be lower. Moreover, the specialists at one facility might deliver more medical services than at the other, affecting a patient’s total costs.

    The simplest and fairest way to ensure everyone can afford their care is a government-administered system for everyone. Such a system could keep costs down through low deductibles and copays, as well as by ensuring everyone pays the same price for a given procedure in a given community. Suggesting that people can shop around for the best health care prices is insane.

    Most people receiving care need care urgently. Those people cannot shop around. But, even people who are receiving elective procedures are hard-pressed to determine where they will save money on care.

    Republicans and Democrats alike also favor regulation of health insurer prior authorization rules. Health insurers are using prior authorization to delay and deny care, inappropriately and with impunity. Through prior authorization, they can spend less and profit more.

    Lastly, Republicans and Democrats support lower prescription drug prices in Medicare through negotiation. Americans should overwhelmingly support drug-price negotiation for more Medicare drugs; we pay as much as four or five times what people in other wealthy countries pay for the same drugs.

    The vast majority of Americans do not support as a priority removing fluoride from our water, as Robert Kennedy Jr. recommends. They also do not support reducing access to abortions or lower federal support of Medicaid as priorities.

    Here’s more from Just Care:

  • Trump’s health care executive orders

    Trump’s health care executive orders

    As with many sectors of our economy, when it comes to health care you should expect a lot of changes from the Trump administration. And, based on Trump’s recent executive orders, millions of Americans could face higher health care and prescription drug costs. Tarena Lofton lays out the latest developments for KFF Health News.

    But, Trump’s most consequential health care act is to push Republicans in Congress to drastically cut Medicaid spending in order to pay for massive tax cuts for the wealthiest Americans. Republicans intend to push through these cuts in a reconciliation package to be finalized shortly. Cuts to Medicaid will affect more than 70 million Americans directly and their families and communities indirectly. If you oppose Medicaid cuts, please reach out to your Congressperson and Senators and let them know.

    Now, to some of the executive orders:

    1. Revoked: Trump revoked a Biden administration executive order requiring the Centers for Medicare and Medicaid Services to focus on new ways to lower prescription drug costs, including a Medicare project that would have established a list of drugs with a $2 copay. The bigger question is whether Republicans will try to undo provisions in the Inflation Reduction Act that allow Medicare to negotiate drug prices and set an annual out-of-pocket cap in Medicare Part D at $2,000.
    2. Revoked: Trump undid a Biden administration executive order that extended the enrollment period for Affordable Care Act health plans, as well as money dedicated to assisting people with enrollment. The bigger question is whether Republicans will end subsidies for people with lower incomes who are insured through the ACA health insurance exchanges. Those subsidies are set to expire at the end of this year.
    3. Withdrawn: Trump withdrew the US from the World Health Organization. The US had been a large supporter, giving the organization $1.3 billion in 2022 and 2023. WHO focuses on global health. It funds health projects around the world and responds to public health emergencies. Trump says he did not like the way the WHO handled the COVID pandemic. The bigger question is how the US will respond to public health emergencies.
    4. Unrecognized: Trump ordered the federal government to not recognize transgender and nonbinary identities. He ended federal support of health care delivered to people on the basis of gender identity. This order will likely be challenged in court. The bigger question is whether this order will be reversed in court.
    5. Expanded: Trump ended a policy that kept immigration officials from arresting people not legally in the US near schools, hospitals and churches.
    6. Withdrawn: Trump withdrew the US from the Paris Climate Agreement for the second time. The agreement specifically states that this process takes a year, but Trump ordered the immediate withdrawal.

    Here’s more from Just Care:

  • Medicare Advantage insurers are killing rural hospitals and communities

    Medicare Advantage insurers are killing rural hospitals and communities

    Write-Off Warrior, a research and advocacy firm that supports rural health systems, just released “Preyed On: How Insurance Corporations are Bleeding Rural Hospitals and Communities to Death.” The report documents the many harmful behaviors of large insurance corporations responsible for endangering the health of rural America. The report also highlights the far-reaching consequences for our country if Congress fails to address insurer behaviors driving rural health disparities.

    Rural Americans represent about 20 percent of the US population. They tend to suffer more from chronic conditions than other Americans. But, they struggle more to get the care they need than other Americans and their plight is worsening.

    The authors surveyed 41 rural hospitals in 15 states across the US and found that the biggest problems they faced were burdensome insurer prior authorization procedures, insurers’ second-guessing of treating physicians, and insurers’ long delays and denials of provider payments. Moreover, insurers take advantage of rural hospitals’ weak bargaining power to negotiate excessively low rates or to keep these hospitals from being in-network. Rural hospitals are foundering.

    Medicare Advantage insurers are the biggest threat to rural hospitals and communities, according to 31 of 41 hospital execs surveyed. These corporate insurers have undermined the hospitals’ financial stability. These insurers have led rural hospitals to end important mental health and rehab services. And, these insurers are leading many rural hospitals to shut down altogether.

    While the top six Medicare Advantage insurers profited to the tune of $41.7 billion in 2023 alone, Medicare Advantage enrollees continue to face rising costs, notwithstanding these insurer practices. They also are often forced to travel long distances for care. Congress must recognize that Medicare Advantage does not work for rural Americans and reform the system.

    Until Congress reforms the Medicare Advantage program to meet the needs of rural Americans, insurers will profit more at the expense of rural communities. Nearly 200 rural hospitals have closed in the last 2o years. And, more than 700 are at serious risk. These hospital closures put rural America on life support.

    Without vibrant rural communities and good rural health, critical food and energy production, vital to the entire country, are at risk of failing.

    Here’s more from Just Care:

  • Want to live longer? Genes and lifestyle matter

    Want to live longer? Genes and lifestyle matter

    Dana G. Smith reports for The New York Times on the extent to which you control how long you live. How much does a healthy lifestyle help and how much do your genes determine your fate?

    For sure, we know about smokers and drinkers, people who eat junk food, as well as people who never exercise, who have lived long and relatively healthy lives. But, the data suggest that these people are the exceptions. If you want to live a long healthy life, you’d better change your lifestyle.

    According to the evidence, your behaviors will likely dictate whether you live until you’re 90. Indeed, one recent study found that you can add 24 years to your life if you: 1. eat healthy, 2. exercise, 3. get adequate sleep, 4. don’t smoke, 5. don’t drink excessively, 6. don’t take opioids, 7. manage stress and 8. engage socially. These healthy behaviors should help you to live to around 87.

    There’s little you can do to help ensure you will live to 100. But, 87 is pretty good relative to most Americans. In the US today, the average life expectancy is 78.5.

    At the end of the day, whether you live a long life depends to the greatest extent on your lifestyle, your daily habits. Genes are responsible only for about 25 percent of your longevity. Living to 100 is far more about your genes than your lifestyle.

    There are plenty of people who live very long lives without particularly healthy habits. They smoke and don’t exercise. Because of their genes, they still are not as likely to have chronic conditions, such as heart disease or cancer or dementia.

    For example, you are better off carrying the APOE2 gene if you are going to avoid an Alzheimer’s diagnosis. If you have the APOE4 gene, you are more likely to be diagnosed with Alzheimer’s. For another example, having the FOXO3 gene can keep you from getting a variety of diseases that generally come with old age.

    Unfortunately, fewer than one in 100 people have these genes. Not surprisingly, fewer than one in 100 people live to 100.

    Here’s more from Just Care:

  • Oncologists report excessive deaths from prior authorization

    Oncologists report excessive deaths from prior authorization

    A new survey from the American Society of Radiation Oncology illustrates the dangers of prior authorization. Prior authorization kills an “inordinate number” of people and harms others. Insurers often deny care to the detriment of patients when physicians first ask for authorization; when denials are appealed, insurers then approve care the vast majority of the time.

    About 225 of the 750 radiation oncologists polled reported adverse health outcomes from prior authorization.  Their patients ended up in the emergency room or hospitalized or with a permanent disability. One in fourteen of the oncologists polled said that one or more of their patients had died as a result of prior authorization.

    Prior authorization can have benefits, particularly in cases in which physicians are not well trained. Prior authorization can ensure physicians are treating patients appropriately, based on evidence. Prior authorization can also keep costs down.

    But, insurers use prior authorization without regard to its effects on quality of life for patients. And, while prior authorization can help protect against unnecessary treatment, there is no one protecting patients from insurers that use prior authorization inappropriately, in ways that harm patients.

    The oncologists polled suggested insurers’ use of prior authorization is only increasing. Moreover, it increases staff burnout.

    • More than nine in ten oncologists (92 percent) reported treatment delays from prior authorization and nearly seven in ten (68 percent) reported delays of at least 5 days;
    • More than eight in ten oncologists (82 percent) blamed prior authorization for patients receiving less than the best care;
    • Nearly six in ten (58 percent) oncologists said prior authorization kept them from following recommended guidelines;

    Those polled made clear that it’s critical to appeal prior authorization denials because more than 70 percent are reversed on appeal. But, patients and physicians sometimes do not have the resources to appeal. In some instances, the tradeoffs of appealing care denials, in terms of time spent, means physicians are unable to do their jobs.

    Moreover, insurers still have 72 hours to review an expedited appeal. For some patients with health insurance, the harm from such a delay is significant.  One doctor said that in that time, “I’ve had patients who’ve literally had a tumor growing out of their chest. Waiting 3 days for an appeal means there’s more cancer to treat, even just in the time between when I made the plan for them initially, and when I actually get to start their treatment. Sometimes it means the plan has to change because the tumor has gotten that much bigger in that time period. Every day matters.”

    Insurers shouldn’t be allowed to continue doing prior authorization for treatments that are virtually always approved on appeal.

    Here’s more from Just Care: