JustCare

Tag: Medicare

  • Trump’s health care plan could be a winning ticket for Biden

    Trump’s health care plan could be a winning ticket for Biden

    Jonathan Cohn reports for the Huffington Post on what Donald Trump claims is his health insurance proposal for Americans. Trump’s proposal would effectively end the Affordable Care Act and offer no viable alternative; it could turn Medicare into a voucher program that drives up costs for older adults and people with disabilities.

    Trump is proposing “less expensive” health coverage than the Affordable Care Act, which effectively would enable insurers to sell junk coverage that won’t meet people’s needs. Trump also would once again allow insurers to stop covering people with pre-existing conditions. And, he would eliminate Medicare’s authority to negotiate prescription drug prices.

    Last November, Trump wrote: “The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives.” Don’t hold your breath.

    While Trump no longer talks of “repealing” the Affordable Care Act, his message is otherwise the same. He knows that Americans don’t want him to repeal the Affordable Care Act, and that Republicans lost control of the House of Representatives and the presidency in part because of their threat to repeal the ACA. Forty-five million Americans now rely on the Affordable Care Act for their health care coverage.

    Not surprisingly, Ronald Brownstein writes for the Atlantic that health care could be a winning issue for the Democrats. It is one major issue that voters trust Biden to address better than Trump. The Republican Study Committee, which represents 80 percent of the House Republicans, has recently said that it would repeal the ACA and restructure Medicare.

    Today less than eight percent of the US population is uninsured as a result of the Affordable Care Act. While that still leaves nearly 30 million Americans without health care coverage, that number is lower than in years past.

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  • Need skilled nursing care? Medicare Advantage insurers often won’t cover it

    Need skilled nursing care? Medicare Advantage insurers often won’t cover it

    Insurers offering Medicare Advantage plans are causing nursing homes to lose money at a rapid pace, reports Amy Stulick for Skilled Nursing News. These insurers are not only paying Medicare-nursing homes less than the traditional Medicare rate, they are too often not covering enrollees’ care in nursing homes, even when they are required to do so. If our government does not step in to insist that insurers pay nursing homes the Medicare rate, there may be no skilled nursing facility care available to Medicare patients.

    Today, Medicare covers care in skilled nursing facilities in limited situations. To qualify for Medicare skilled nursing care, patients must need daily skilled nursing or therapy services and receive these services in a Medicare-certified skilled nurse facility. Moreover, they must be hospitalized for at least three days in the 30 days prior to admission to a skilled nursing facility. So long as they qualify, Medicare covers up to 100 days of care per benefit period.

    But, insurers offering Medicare Advantage plans don’t like to spend the money they receive to cover Medicare services. Every service they do not cover is money in their pockets. So, people in Medicare Advantage plans often do not get nursing home care or get very limited nursing home care or get poor quality nursing home care.

    Marc Zimmet, the president of Zimmet Healthcare says that nursing homes are losing $274.9 million for every one percent increase in Medicare Advantage enrollment. Traditional Medicare pays about 87 percent more ($841) for nursing home care than insurers offering Medicare Advantage ($448). Not surprisingly, Medicare Advantage enrollees not only get less nursing home care than traditional Medicare enrollees, they are forced to use lower quality nursing homes.

    People enrolled in Medicare Advantage need to recognize that they are taking a big risk with their health. They can’t count on getting high quality physician and hospital care; they can’t count on continuity of care; they can’t count on getting needed care. Yes, it is true that some people do perfectly well in Medicare Advantage; it’s also true that hundreds of thousands, if not millions, experience serious deterioration of their health and tens of thousands die needlessly. With Medicare Advantage, you are always playing the odds; you could end up in a killer plan.

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  • House Republicans call for major cuts to Social Security and Medicare

    House Republicans call for major cuts to Social Security and Medicare

    Former President Trump does not want to admit that he supports major cuts to Social Security and Medicare, even though he has said so. He has backed off those comments. But, Republicans in the House of Republicans are underscoring their desire for major cuts to Social Security and Medicare, report Brett Arends for MarketWatch and Ellie Quinlan Houghtaling for TNR.

    The proposed 2025 Republican budget from the Republican Study Committee in the House of Representatives calls for slashing $2.7 trillion from Social Security and Medicare over the next ten years. And, that’s not all. The House Republicans want to raise the age of retirement, which could mean delaying Medicare and Social Security benefits or, at the very least, reductions to those benefits.  

    To be clear, nothing is clear about the Republican plan other than a desire to cut taxes and spend less on Medicare and Social Security. Republicans see no need to raise taxes on the wealthiest Americans.

    A recent Gallup poll found that 61 percent of Americans support raising taxes to “ensure Social Security’s long-term future” as compared to 31 percent who support curbing “the amount of benefits for future Social Security recipients.”  Arends notes that the percentage of Americans who favor raising taxes to strengthen Social Security has grown significantly over the last 15 years.

    Republicans in Congress appear to care little that the majority of Americans, including Republican voters, want to strengthen Social Security through tax increases. They do not want to cut Social Security. However, the Republican Study Committee does attempt to stave off any hostility from people receiving Medicare and Social Security today; their proposal does not affect these Americans.

    If they could, Republicans would turn Medicare into Medicare Advantage exclusively and likely cut back on payments to Medicare Advantage plans, driving up costs for older adults and people with disabilities, particularly those who need costly care.

    While the Republican Study Committee might not be helping former president Trump by speaking out for Medicare and Social Security cuts, I give the Republicans credit for not hesitating to speak their mind. The Republicans know it’s a long game to achieve these cuts and that’s the hand they are playing.

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  • 2024: Programs that lower your health care costs if you have Medicare

    2024: Programs that lower your health care costs if you have Medicare

    Medicare only covers about half of a typical person’s health care costs, leaving people with average annual out-of-pocket costs of $7,000. So, even with Medicare, many people struggle to afford premiums, deductibles and other costs. Some people qualify for Medicaid, which fills most of the gaps in Medicare. But, if you do not qualify for Medicaid, there are other programs that lower your health care costs. Click here or contact your local State Health Insurance Assistance Program (SHIP) to find out if you are eligible for any of these programs and how to apply.

    1. Medicare Savings Programs. Depending on your income, Medicare Savings Programs, administered by Medicaid, help pay for Medicare premiums and coinsurance, even if you don’t qualify for Medicaid. There are three programs, Qualified Medicare Beneficiary (QMB), Specified-Low Income Medicare Beneficiary (SLMB) and Qualified Individual (QI). Income and asset limits, and how they are counted, are listed below for 2024, but vary somewhat by state. You might still qualify for these programs in your state even if your income or assets are higher than the federal amounts listed below. States sometimes exclude certain income and assets when determining your eligibility. You should apply through your state Medicaid office.

    • Qualified Medicare Beneficiary (QMB)—100 percent of federal poverty level (FPL) + $20. If you have QMB, you should not have out-of-pocket costs for Medicare-approved services in traditional Medicare or for in-network services in a Medicare Advantage plan. It should cover premiums, deductibles, coinsurance and copays for Medicare-covered services.
      • Income limit monthly depends upon where you live but is around
        • $1,275 for individuals
        • $1,724 for couples
      • Asset limit
        • Individuals: $9,430
        • Couples: $14,130
    • Specified Low-income Medicare Beneficiary (SLMB)—120 percent of FPL + $20. SLMB helps pay your Medicare Part B premium, if you have Part A and Part B.
      • Income limit monthly depends upon where you live but is around
        • $1,526 for individuals
        • $2.064 for couples
      • Asset limit
        • Individuals: $9,430
        • Couples: $14,130
    • Qualifying Individual (QI)—135 percent of FPL +$20, helps pay your Medicare Part B premium if you have Medicare Part A and Part B.
      • Income limit monthly depends upon where you live but is around
        • $1,715 for individuals
        • $2,320 for couples
      • Asset limit
        • Individuals: $9,430
        • Couples: $14,600

    Several valuable items are not counted as income and assets. No matter what state you live in, the first $20 of your income and the first $65 of your monthly wages are not counted as income. In addition, half of your monthly wages, after the first $65 is not counted, nor are food stamps. Some of your assets are also not counted, including your primary home, if you own it, your car, your wedding and engagement rings, a burial plot and $1,500 in burial funds, your life insurance with a cash value less than $1,500, and your furniture, household and personal items. Your bank accounts, stocks and bonds are counted.

    Tip: If your income is low but too high to qualify you for Medicaid, it is worth looking into whether you qualify for any of these programs. According to MACPAC, an independent agency that advises Congress on Medicaid policy, less than a half the people over 65 who qualify for the Qualified Medicare Beneficiary program (48%) are enrolled. And, an even smaller share of people over 65 who qualify for the Specified Low-Income Medicare Beneficiary program (28%) are enrolled. About one in seven people over 65 (15%) who qualify for the QI program are enrolled.

    2. Extra Help with Medicare Part D prescription drug coverage: You will automatically qualify for the Extra Help program, which is administered by Medicaid, if you qualify for Medicaid or any of the above low-income programs or receive Supplemental Security Income benefits. You can also apply for Extra Help independently. Extra Help pays for some or all of the cost of your Part D drug coverage and is estimated to be worth around $5,100 a year. The amount of help with cost-sharing depends on the level of your income and assets. In 2024, you may qualify if you have up to $22,590 in annual income ($30,660 for a married couple) and up to $17,220 in assets ($34,360 for a married couple). With Extra Help your drug costs are no more than $4.50 for each generic/$11.20 for each brand-name covered drug. If your total drugs costs–what you and your health plan pay) go above $8,000 this year, you’ll pay nothing more. And, depending upon your income, you may pay only part of your Medicare drug plan premiums and deductibles. (Some states have State Pharmaceutical Assistance Programs that provide even more assistance.)

    3. Federally Qualified Health Centers (FQHCs) and other programs run by the Human Resources and Services Administration: FQHCs are located across the country and provide a wide range of services to underserved populations and areas on a sliding-fee scale. They might waive the Medicare deductible and coinsurance, depending upon your income.

    4. Hill-Burton programs offer free or reduced care at Hill-Burton facilities in 38 states. Hill-Burton does not cover services fully covered by Medicare or Medicaid. Eligibility depends on your family size and income.

    5. Veterans’ Administration: If you are a vet, the Veterans’ Administration (VA) offers low-cost services and prescription drugs directly. And, you can have VA coverage as well as Medicare.

    Keep in mind that you may be eligible for Medicaid based on your income after paying for some health care costs. To contact your state Medicaid office, click here.

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  • Want to strengthen Social Security and Medicare, not cut them? Vote Biden

    Want to strengthen Social Security and Medicare, not cut them? Vote Biden

    Paul Krugman explains in a New York Times opinion piece why older adults and people with disabilities who support strengthening Medicare and Social Security need to vote in the upcoming presidential election: Medicare and Social Security are on the ballot. Only Joe Biden stands with them.

    President Biden’s 2025 fiscal budget proposes to increase taxes to protect and strengthen Social Security and Medicare. In stark contrast, former President Donald Trump has been calling for cuts to these programs. Krugman reminds us that Biden’s position is more in keeping with the public than Obama’s.

    In the past, President Obama and some other Democrats have called for limiting Medicare and Social Security spending, without regard to its consequences. Limits to Medicare spending would mean higher health care costs for older adults and people with disabilities. Limits to Social Security spending would mean lower benefits down the road and less retirement income.

    President Biden is proposing higher Social Security benefits and paying for them through higher corporate taxes. Wealthy individuals, who now contribute to Social Security for just a part of the year, unlike everyone else, and who don’t make Social Security contributions on capital gains income, would have to pay their “fair share.”

    To strengthen Medicare, President Biden proposes that people with annual incomes above $400,000 would pay a slightly higher Medicare tax rate. Their Medicare tax rate on earned and unearned income would increase from 3.8 percent to 5 percent. A majority of voters have always supported raising taxes on the wealthy to strengthen Medicare and Social Security.

    In stark contrast, here’s what Trump says:  “There is a lot you can do in terms of entitlements, in terms of cutting and in terms of also the theft and the bad management of entitlements.”  The Trump campaign insists that Trump did not actually mean “cutting.”

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  • Will FDA approval of Wegovy to treat heart conditions mean more people with Medicare can fill a weight-loss prescription?

    Will FDA approval of Wegovy to treat heart conditions mean more people with Medicare can fill a weight-loss prescription?

    The FDA recently approved Wegovy, a weight-loss drug, to treat overweight people with heart conditions. Will that mean that more people with Medicare will get their weight-loss drugs covered? Maya Goldman reports for Axios on what the Centers for Medicare and Medicaid Services (CMS), which oversees Medicare, as well as the insurers offering Medicare Part D prescription drug coverage, are considering.

    At the moment, CMS has not decided whether Medicare will cover Wegovy as a treatment for overweight people with heart conditions. To date, Medicare has not covered any weight-loss drugs simply for the purpose of helping people lose weight. But, Medicare does cover weight-loss drugs as a treatment for people with diabetes.

    Medicare, by law, covers only treatments for medically reasonable and necessary services. CMS does not consider treatment for weight loss as reasonable and necessary. Treatment for a heart condition, much like treatment for diabetes, is very different.

    About 40 percent of people with Medicare have heart conditions. That’s more than 24 million people. And, likely a sizeable number of them are overweight. So, Medicare might end up covering Wegovy for them.

    Of note: Wegovy costs about $1,200 a month. Covering it for even four million more people will likely cause Medicare spending to balloon. Fortunately, people with Medicare should not see their costs balloon. Beginning in 2025, people’s annual out-of-pocket costs for covered prescription drugs will be capped at $2,000.

    For now, insurers offering Medicare Part D prescription drug coverage are waiting for CMS to rule on the conditions under which Medicare will cover Wegovy. Part D insurers could, of course, decide to cover Wegovy without waiting for CMS, but that would cost them a bundle. Their Medicare payments for this year are already set.

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  • People with Medicare spend twice as much on healthcare as other people

    People with Medicare spend twice as much on healthcare as other people

    People with Medicare spend twice as much on healthcare as other people, according to a new Kaiser Family Foundation report. On average, people with Medicare spend $7,000 a year or 13.6 percent of their total household spending a year. People under 65 spend about 6.5 percent of their income or $4,900 a year.

    Higher spending for Medicare population is not surprising. People with Medicare on average have lower incomes than younger working people. Annual average household income for working people is $74,100 as compared with $51,800 for people with Medicare. And, of course, people with Medicare use significantly more health care services than younger working people.

    These healthcare expenses for people with Medicare represent a bigger portion of their income than health care expenses for younger working people. What’s noteworthy is that as a share of total household spending, people with Medicare’s health care expenses are about the same in 2022 as they were in 2013.

    The Inflation Reduction Act could lower people with Medicare’s out-of-pocket healthcare costs somewhat. It caps prescription drug costs under Medicare Part D at $2,000 a year for covered drugs, beginning in 2025. And, it brings down the costs of some high-cost drugs beginning in 2026. It will also be easier for people to qualify for extra help paying their prescription drug costs as Congress has expanded access to these subsidies.

    People with Medicare still need to buy supplemental coverage to fill gaps in traditional Medicare unless they have Medicaid or subsidized employer retiree coverage. If they are in a Medicare Advantage plan, they can pay as much as $8,700 a year in out-of-pocket costs for in-network care alone, though on average Medicare Advantage plans cap their costs at around $5,000 a year for in-network services (about twice the cost of Medicare supplemental coverage.)

    Here’s more from Just Care:

  • Some Democrats oppose Biden’s goal of lowering more Medicare drug prices

    Some Democrats oppose Biden’s goal of lowering more Medicare drug prices

    The Lever reports on a cadre of Democratic Congressmen committed to opposing Biden’s goal of lowering more drug prices for people with Medicare. Not surprisingly, these policymakers happen to be the beneficiaries of lots of pharmaceutical industry money. What’s going on?

    The Inflation Reduction Act includes provisions to allow Medicare to pay negotiated drug prices for ten drugs in 2026. It allows Medicare to negotiate drug prices for an additional 150 drugs through 2034. President Biden wants to expand that number to 500 drugs, which would reduce Medicare spending on high-cost drugs and should also reduce people’s copays for those drugs.

    Former President Trump, if reelected, appears interested in weakening Medicare drug-price negotiation. At one point during his presidency he said he supported drug price negotiation, but he has since backed down from that position.

    Democrats Scott Petters of California, Josh Gottheimer of New Jersey, and Wiley Nickel of North Carolina are prepared to go against their president and fight some Medicare drug price negotiation as well. The pharmaceutical industry and other medical industry groups have contributed $300,000 to them in the last year. Gottheimer is considering a run for governor of New Jersey.

    These Democrats are sponsoring legislation that claims to be defending research on orphan drugs, aping the drug industries’ common refrain that negotiated drug prices will compromise investment in research. It is interesting how negotiated drug prices around the world don’t appear to concern them or the fact that Americans are forced to pay three or four times as much as people in other wealthy countries for the same drugs.

    Experts say that pharmaceutical companies will still rake in big profits on orphan drugs with negotiated prices, just not quite as big as they do now. Moreover, the Inflation Reduction Act exempts “orphan drugs” from Medicare price negotiations if they are treating only one rare disease. If Peters, Gottheimer and Nickel get their way, orphan drugs would be excluded from Medicare price negotiations even if they treat multiple rare conditions.

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  • What could a better Medicare look like?

    What could a better Medicare look like?

    A new report from the Center for American Progress focuses on Medicare as a great American success story. Yet, it recognizes that Medicare needs improvements for its long-term sustainability, for easy access to affordable care for the tens of millions of older adults and people with disabilities it serves, for promoting health equity, for improving population health and more.

    Traditional Medicare comes with high cost-sharing and no out-of-pocket cap, as well as a fragmented structure that requires the separate purchase of Part D prescription drug coverage and supplemental coverage to fill gaps in Medicare. Medicare Advantage comes with a defective payment system that leads to massive overpayments and incentivizes insurers to design their health plans to attract the healthy and avoid the sick in order to maximize profits.

    The authors of this report believe that strengthening and improving Medicare benefits would offer a strong counterbalance to opposition from health insurers over ending their overpayments. The goal therefore is to link Medicare enhancements to reform of the Medicare Advantage payment system.

    The new Medicare would guarantee people easy affordable access to the care they need, including prescription drugs and primary care, while promoting population health and health equity. In Medicare Advantage, people and providers often face inappropriate denials of care and coverage. People also face inadequate provider networks that keep them from getting the care they need.

    A stronger Medicare would also cover in-home and community long term services and supports. Today, Medicare only covers skilled nursing home care for people who have been hospitalized for at least three days prior to admission and need daily skilled care. And, coverage is for no more than 100 days. Medicare Advantage plans tend to limit that coverage to a few days at most.

    Vision, hearing and dental care would also be part of the Medicare benefit package. While some Medicare Advantage plans claim to cover one or more of these services, people in Medicare Advantage don’t tend to receive them any more than people in Traditional Medicare because out-of-pocket costs are still very high and network providers are limited. People in Medicare Advantage pay 65 percent of vision costs, 76 percent of dental costs, and 79 percent of hearing costs.

    To lower administrative expenses for providers and payers and ensure people in Medicare Advantage actually get the Medicare benefits to which they are entitled, the authors propose that Medicare Administrative Contractors—which today process claims in traditional Medicare—do so for Medicare Advantage plans as well.

    The authors further propose lower out-of-pocket costs in traditional Medicare. Lower costs would make it much easier for people to move from Medicare Advantage to Traditional Medicare. Currently, most people are locked into Medicare Advantage because they cannot afford or cannot secure supplemental coverage to limit their financial risk in traditional Medicare, which lacks an out-of-pocket cap.

    With regard to prescription drugs, the authors say that drug pricing must be fair and reward meaningful innovation. They point out that insurers offering Medicare Advantage plans create drug formularies that are especially costly for people with expensive conditions in order to keep these high-cost individuals from enrolling. The authors recommend no cost or low copays for drugs that are of critical benefit to patients.

    The authors envision promoting population health through “a payment policy oriented toward medical and social needs [that] would pay providers more for [a] patient[s] [who is vulnerable] to enable what [he] really needs—for instance, his clinic builds a diabetes registry, a population health manager identifies that he has not had a recent visit, a community health worker calls him and helps him arrange a free ride to the clinic through a local program, and his doctor checks his lab work and starts him back on medications for his diabetes. A nurse calls him afterward to make sure he was able to start taking the medication and to review his follow-up plan. The infrastructure that helps this patient—chronic disease registries, population health managers, community health workers, community partnerships, team-based care—enables the health care organization to manage population health for the community it serves.”

    Here’s more from Just Care:

  • New poll confirms serious access to care concerns in Medicare Advantage

    New poll confirms serious access to care concerns in Medicare Advantage

    While all insurers offering Medicare Advantage (MA) profit more the less care they deliver, every Medicare Advantage plan is different; we should not generalize about them. We know that access to care can be a serious issue in MA, with some insurers using artificial intelligence to deny care, others relying on prior authorization requirements to delay and deny care and others offering provider networks that do not meet enrollees’ needs. A new Commonwealth Fund survey confirms that access to care continues to be a far more serious concern for MA enrollees than for Traditional Medicare (TM) enrollees.

    The Commonwealth Fund survey of more than 3,200 people with Medicare found that more than one in five people (22 percent) enrolled in Medicare Advantage reported delays in receiving care, as compared with one in eight (13 percent) enrolled in Traditional Medicare.

    Wait times to see physicians did not vary between people in Traditional Medicare and people in Medicare Advantage. But, one in three people polled said they waited more than a month to see a physician.

    People in MA reported significantly higher financial barriers to care than people in Traditional Medicare. Twelve percent of people in MA faced cost barriers to care, in the form of either a deductible or a copay, as compared with seven percent of people in Traditional Medicare. The five percent difference is especially telling, given people in MA overall are healthier than people in TM.

    Satisfaction was relatively the same for people with Traditional Medicare and Medicare Advantage.

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