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Tag: Pramila Jayapal

  • Attention mounts on Medicare Advantage fraud and abuse

    Attention mounts on Medicare Advantage fraud and abuse

    More Democrats and Republicans in Congress are speaking out and raising alarms about Medicare Advantage. If Republicans need to find savings to pay for their tax cuts, they need look no further than the $1 trillion in Medicare Advantage overpayments.

    A growing number of Republicans are speaking out against these massive government overpayments to Medicare Advantage insurers. At a recent Senate Finance Committee hearing, Senator Roger Marshall (KA-Rep) said: “Like Dr. Oz, I thought Medicare Advantage was a good thing when it came out. But, unfortunately, it’s been manipulated. They found loopholes to manipulate and now we’re spending probably $83 billion more a year on Medicare Advantage patients as opposed to if they had been on traditional Medicare…I hope that there’s an opportunity to fix that very broken system that friends across the aisle who speak so boldly about Medicare Advantage that they will vote for reforming it as well whenever we have that opportunity.”

    Senator Chuck Grassley (Rep-IO) has expressed similar concerns about Medicare Advantage, as have Senators Bill Cassidy (Rep-LO) and James Lankford (Rep-OK), who recognizes inappropriate denials in Medicare Advantage, which are keeping some hospitals in his state from contracting with MA insurers.

    Indeed, increasingly, hospital systems, including some of the best hospital systems in the country are dropping Medicare Advantage contracts. 

    Seventy-eight Democrats in the House of Representatives wrote HHS Secretary Kennedy and Acting CMS Administrator Carlton to express their concerns about Medicare Advantage overpayments and more.”If Republicans were serious about combating waste, fraud and abuse, they would be focused on Medicare (dis)Advantage plans,” says Representative Pramila Jayapal (CA-Dem) on MSNBC.

    Eight Democrats in the Senate sent a similar letter.

    Eileen Appelbaum, health economist at the Center for Economic and Policy Research, explains the Medicare Advantage rip-off here:

    Here’s more from Just Care:

  • Americans are not getting their money’s worth from our health care system

    Americans are not getting their money’s worth from our health care system

    Elon Musk, the billionaire whom Trump has nominated to head the Department of Government Efficiency (DOGE) in his administration, asked on X why Americans are not getting their money’s worth from our health care system. Congresswoman Pramila Jayapal and Senator Bernie Sanders have an answer: If we want a cost-effective system, we need single-payer, one government-administered health care system for everyone. It’s that simple.

    For years, Sanders and Jayapal have been outspoken in their critique of the US for-profit health care system. They welcomed Musk’s criticism of the current system that leads to out-of-control health care costs. And, they have asked him to support Medicare for all. Each year, they have introduced legislation to enact Medicare for all, but the needed support for the legislation is not yet there.

    Most Americans agree with Musk that they are not getting their money’s worth. Insurer administrative costs alone for each American is now well over $1,000 a year. That’s more than three times higher than administrative costs in Canada, Japan, South Korea, and every European country. In Japan, administrative costs per person are $82. In the United Kingdom and Sweden, they are $97. In Germany, they are $306, higher than every other country except the US. Average administrative costs are $194 per person.

    On top of exorbitant insurance premiums, insured Americans spend an average of $1,132 a year on out-of-pocket health care costs. Deductibles, coinsurance and copays are high.

    In 2020, in the final year of the last Trump Administration, a Congressional Budget Office report found that a government-administered health insurance system would save the US  about $650 billion each year.

    Here’s more from Just Care:

  • Sen. Warren and Rep. Jayapal urge CMS to end Medicare Advantage overpayments, punish bad actors

    Sen. Warren and Rep. Jayapal urge CMS to end Medicare Advantage overpayments, punish bad actors

    Ahead of the Centers for Medicare and Medicaid Services’ (CMS’) release of proposed payment policy for Medicare Advantage plans, Senator Elizabeth Warren and Representative Pramila Jayapal sent a letter to the Centers for Medicare and Medicaid Services detailing ways the administration could wipe out a projected $100 billion in overpayments to MA plans this year alone. Among other things, the letter proposes ending contracts with MA plans that violate their duty to cover Medicare benefits.

    “It is imperative for [Medicare] to rein in these abuses and protect Medicare coverage for the seniors and people with disabilities who rely on it,” say Warren and Jayapal. Last month, Senator Warren wrote CMS to start collecting critical data needed to oversee the Medicare Advantage plans.

    Thirty-one million older adults and people with disabilities are enrolled in Medicare Advantage plans. These health plans cost taxpayers $500 billion last year. But, substantial evidence indicates that the government overpays insurers offering these plans tens of billions of dollars each year; and, some, if not many, of these MA plans inappropriately deny and delay care to their enrollees, especially care for people with complex and costly conditions.

    The Biden administration has taken some steps to end some of the overpayment abuses. But, many experts believe there’s a lot more to be done. Mark Miller, former director of the Medicare Payment Advisory Commission, says “If [the Centers for Medicare and Medicaid Services] backs down … then the beneficiary and taxpayer lose.”

    CMS gave the insurers immunity from overpayments detected over seven years of audits. CMS now plans to conduct more auditing of MA plans’ billing processes. Warren and Jayapal are looking for payment policy changes as well as audits. For example, they want the government to adjust payments to MA plans because their enrollees are healthier than enrollees in Traditional Medicare.

    The five-star quality rating system for MA plans also needs an overhaul. People cannot rely on the star-rating system as an indicator of whether an MA plan inappropriately denies care or has a narrow network that undermines their ability to get good care. Yet, the government pays insurers more for MA plans with a 4 or 5 star-rating.

    Moreover, some data show that some MA plans provide their enrollees fewer benefits than they would get in Traditional Medicare, even though they are legally required to cover the same benefits. CMS has not penalized plans that inappropriately deny care. Warren and Jayapal want CMS to hold them accountable and end their contracts.

    In some instances, UnitedHealth Group has denied rehab care to patients in critical need of rehab, based on computer algorithms, to the detriment of their enrollees’ health and well-being. Even though CMS said it may punish insurers who violate their contracts by wrongly denying care, it has yet to do so.

    CMS has ended contracts with Centene Medicare Advantage plans in Arizona and North Carolina because their star-ratings were three or below for three years running.

    Here’s more from Just Care:

  • Congresswomen Jayapal and Dingell introduce Medicare for All Act

    Congresswomen Jayapal and Dingell introduce Medicare for All Act

    Today, Congresswomen Pramila Jayapal and Debbie Dingell, along with 110 co-sponsors in the House of Representatives, introduced the Medicare for All Act of 2021. The Medicare for All Act of 2021 is a win for everyone in the US, and most importantly for older adults and people with disabilities.

    The Medicare for All Act guarantees everyone coverage from the doctors and hospitals they want to use, with no deductibles, coinsurance or copays. It ends the practice of rationing care based on ability to pay and promotes health equity.

    The Medicare for All Act covers long-term care, meaning nursing home care as well as home and community-based care, so that people can age in place. Older adults and people with disabilities would no longer have to go without long-term supports and services or go broke paying for them. 

    The Medicare for All Act also improves Medicare benefits, adding hearing, dental and vision coverage. These benefits are covered in full, with no out-of-pocket costs.  

    In addition, the Medicare for All act would enable the government to collect data on what’s working and not working in our health care system and to identify and respond to problems that need addressing. Right now, private health insurers hide that data, undermining health care system improvements.

    As important, during a pandemic, Medicare for All would allow the government  to see where resources needed to be deployed and ensure that everyone received free testing and treatment. In sharp contrast, private insurers, including private Medicare Advantage plans, have kept millions of Americans from getting needed COVID-19 services and treatments. Their deductibles, copays and coinsurance have posed barriers to care.

    Traditional Medicare–government administered public insurance–has proven itself to be far more cost effective than private insurance. It gives people the open access to doctors and hospitals that they want and need. It’s transparent. It allows the government to drive system improvements.

    The Medicare for All Act expands traditional Medicare’s benefits and guarantees everyone in the US a cost-effective, high-value health care system that we all desperately need.

    For all these reasons, Just Care USA strongly endorses the Medicare for All Act of 2021.

    Here’s more from Just Care:

  • Coronavirus: Sanders’ legislation would pay for everyone’s care during this pandemic through Medicare

    Coronavirus: Sanders’ legislation would pay for everyone’s care during this pandemic through Medicare

    Last Friday, Senator Bernie Sanders (I-Vt.) introduced the Health Care Emergency Guarantee Act which guarantees everyone in the US the ability to get health care without having to pay deductibles, coinsurance or other out-of-pocket costs during the coronavirus pandemic. Six other senators cosponsored the legislation: Senators Kirsten Gillibrand (D-N.Y.), Edward Markey (D-Mass.), Elizabeth Warren (D-Mass.), Cory Booker (D-N.J.), Jeff Merkley (D-Ore.), and Kamala Harris (D-Calif.)

    The goal of the legislation is to ensure no one skips or delays care during this pandemic because of the cost. Americans should be able to get care without worry about whether they can afford it. The legislation covers all costs for people who are uninsured and all out-of-pocket costs for everyone else. And, it would stay in place until everyone was able to get a COVID-19 vaccine.

    The legislation, which is like the Medicare Crisis program sponsored by Representative Pramila Jayapal, is cost-effective and comprehensive. It relies on Medicare to cover people’s care, including prescription drugs, with federal dollars. In Sanders’ words, “When so many people in this country are struggling economically and terrified at the thought of becoming sick, the federal government has a responsibility to take the burden of health care costs off the backs of the American people. The legislation we are introducing today does just that.”

    The public is solidly behind Senator Sanders’ proposal. A Data for Progress poll finds that nearly three in four voters (73 percent) favor having the federal government pay for people’s out-of-pocket health care costs during the pandemic. Notably, a majority of Republicans (58 percent) favor the legislation.

    Far fewer voters support a proposal passed in the House of Representatives that pays the health insurance premium of people who have lost their employer coverage, through COBRA. Not only is Sanders’ proposed legislation less costly, it is also more comprehensive. If Congress pays for people’s COBRA coverage, people are still left with deductibles and coinsurance, along with restricted networks and other bureaucratic hassles. Deductibles in employer health plans average $1,800 a year. Moreover, people who did not have employer coverage who lost their jobs are left without any coverage.

    In fact when voters understand the difference between the two proposals, 61 percent favor Sanders’ bill versus 14 percent who favor  the COBRA bill. The COBRA bill benefits health insurers most; they would reap tens of billions of dollars in revenue if the Senate passes it. It only benefits the uninsured who had employer coverage if they can afford the out-of-pocket costs of their care

    The Sanders bill also prevents hospitals and other health care providers and debt collectors from collecting medical debts, forbids private insurance companies from raising out-of-pocket costs and mandates data collection and reporting regarding COVID-19 health disparities.

    Everyone in the country needs to be able to get treatment for the novel coronavirus before it is safe to reopen the economy. Moreover, the pandemic reveals how critical it is to everyone that anyone who is sick can get the care they need as quickly as possible. That is how to contain the virus.

    More than 30 national organizations and unions support the Health Care Emergency Guarantee Act. You can read the bill here.

    Here’s more from Just Care:

  • Coronavirus: What would it cost the federal government to pay for health care through Medicare?

    Coronavirus: What would it cost the federal government to pay for health care through Medicare?

    Economists at the University of Massachusetts, PERI, have just released a report analyzing the cost of the Medicare Crisis program, a program proposed by Representatives Pramila Jayapal and Joe Kennedy to help 95 million people afford needed health care during the coronavirus pandemic. The researchers find that the cost to the federal government of the Medicare Crisis program is far less than the cost of a proposal by Representative Bobby Scott, which would subsidize COBRA coverage for people who have lost their jobs and their employer coverage.

    Notably, the Medicare Crisis program covers many more people and provides far more generous benefits than the Worker Health Care Protection Act, the bill which would subsidize the cost of COBRA coverage for people who have lost their employer coverage. Specifically:

    • The Medicare Crisis program covers all recently unemployed workers–around 19.2 million people–and their families, regardless of whether they had health insurance through their jobs. The COBRA bill only covers recently unemployed workers who have lost employer coverage–around 12.9 million people–and their families.
    • The Medicare Crisis program covers all health care costs, including deductibles and copays, for all COVID-related care for unemployed workers and their families. The COBRA bill only covers health insurance premiums and does not cover deductibles and copays for any care.
    • The Medicare Crisis program covers all out-of-pocket COVID-19 costs for people with traditional Medicare and people in Medicare Advantage. The federal government picks up the cost for people in traditional Medicare, and Medicare Advantage plans pick up the cost for their members. The Medicare Crisis program also covers Part A and Part B premiums for people in traditional Medicare.
    • The Medicare Crisis program caps out-of-pocket costs for non-COVID care for unemployed workers and people in traditional Medicare at five percent of their monthly income. The COBRA bill does not cover these costs at all.

    The cost to the federal government of the Medicare Crisis program to cover 38.7 million people is $22.7 billion less than the full cost of care for the same number of people under the COBRA bill, $47.5 billion versus $69.8 billion for three months of care. The Medicare Crisis program is far less costly because the federal government would be paying directly for care; it would not be paying private insurance premiums to health insurance companies to cover possible care people received; it also would not be paying the high administrative costs and profits that come with relying on private health insurers. And, it would be paying lower rates; Medicare provider rates are about two-thirds of private insurance rates.

    Here’s more from Just Care:

  • Coronavirus: How best to guarantee everyone access to care

    Coronavirus: How best to guarantee everyone access to care

    In the face of the coronavirus pandemic, members of Congress are proposing all sorts of ways to help people get health care. One Democratic proposal would be a handout to the health insurance industry; it would cover insurance premiums for ex-workers but require them to pay high deductibles and coinsurance. Senator Bernie Sanders and Congresswoman Pramila Jayapal have a cost-effective proposal that would guarantee everyone 100 percent coverage and easy access to health care.

    The Sanders-Jayapal bill, the Health Care Emergency Guarantee Act, would have the federal government pay through Medicare all costs for COVID-19 care that are not covered through their insurance. And, for anyone without insurance, the federal government would pay for the full cost of their health care. No one would have to pay the deductible or coinsurance in order to get needed care. No one would fall into medical debt if they sought care. And, no one would go without health care because they could not afford it.

    From the perspective of the federal government, the Sanders-Jayapal solution would be cost-effective. The federal government would only pay for services people received. It would not pay the cost of people’s insurance, which would require it to pay even for people not getting care. Moreover, it would pay doctors and hospitals Medicare rates which are lower than private insurance rates.

    The Sanders-Jayapal bill has the added advantage of creating a single real-time electronic billing record for all Covid-19 care. The data would help to track the virus as it moves around the country and provide guidance as to where resources need to be deployed.

    Here’s more from Just Care:

  • Five arguments for Medicare for All

    Five arguments for Medicare for All

    As we continue to debate how to move forward on health reform, it’s helpful to understand the key arguments for Medicare for All, a single-payer public health insurance system that would guarantee health care coverage to all Americans. As proposed by Senator Bernie Sanders and Congresswoman Pramila Jayapal, Medicare for All, like traditional Medicare, allows you to use the doctors and hospitals you want to use; and, it improves on traditional Medicare, adding benefits and eliminating premiums, deductibles, coinsurance and copays.

    Here are five key arguments for Medicare for All:

    1. Medicare for All guarantees health care coverage to everyone with no out-of-pocket costs, increasing access to care, promoting equality in our health care system, and eliminating the rationing of care based on ability to pay. It offers more comprehensive benefits than private insurance or Medicare today, including dental, vision, hearing and home and community-based care, along with standard benefits.
    2. Medicare for All simplifies the health care system. It alleviates a lot of confusion, bureaucratic headaches and stress that come with allowing multiple payers to each have their own set of rules. It also makes it easier for businesses to compete in the global marketplace, relieving employers of the responsibility of providing their workers health care coverage.
    3. Medicare for All covers care from virtually every hospital and doctor anywhere in the US, giving people far greater choice of providers than most have today and ensuring continuity of care from one year to the next. It also means an end to surprise medical bills.
    4. Medicare for All brings down health care spending. It reduces administrative costs and provider rates by hundreds of  billions of dollars a year. It eliminates as much as $500 billion a year in administrative waste–the costs imposed by private insurers stemming from rate negotiation, medical underwriting, and claims processing. And it eliminates hundreds of billions more in excess prescription drug and provider rates. There’s no reason Americans should pay twice as much as people in other wealthy countries for our drugs, and equally no reason that a hip replacement or an MRI should cost four times more in one hospital than in another.
    5. Medicare for All reduces administrative costs for doctors and hospitals, saving them tens of billions of dollars each year. They would no longer have to hire as many administrative staff to deal with scores of insurers on prior authorization, referrals, provider rates, copays, claims processing and appeals.

    Here’s more from Just Care:

  • KamalaCare leaves health insurers running the show

    KamalaCare leaves health insurers running the show

    There’s no question that the American health care system is a crazy quilt that leaves health “insurance companies in charge,” as Senator Kamala Harris appreciates. Unfortunately, her health reform proposal, “KamalaCare” does not match her rhetoric. It leaves health insurers running the show.

    Harris’ proposal relies extensively on for-profit health insurers to provide coverage. But, they are the reason health care is unaffordable and the reason people are often faced with denials of care and coverage. She claims her plan will hold the health insurers to account if they game the system. That sounds great in theory, but how exactly would it work in practice?

    Like Senator Bernie Sanders’ and Congresswoman Pramila Jayapal’s Medicare for All legislation, Harris’ proposal makes an improved traditional Medicare public plan available to all Americans. Unlike Sanders and Jayapal, after a ten-year transition, she keeps the for-profit health insurance industry in business, offering Medicare Advantage plan options to people who want a private plan.

    Harris does not explain what her multi-payer plan would do to reduce the $503 billion a year in administrative costs in our health care system. She also does not explain how it will rein in doctor and hospital rates. She does say that she would cut prescription drug prices so that we pay what other wealthy countries pay for our drugs. And, while that could save as much as $250 billion a year, it is not the hundreds of additional billions in savings we achieve from the Sanders and Jayapal Medicare for All bills.

    Consequently, it is hard to see how Harris makes health care affordable. Today, annual out-of-pocket limits in Medicare Advantage plans are $5,059 for in-network care alone. What would change?

    Putting costs aside, like many other pundits and candidates, Harris believes that people want health insurance plan choices more than they want affordable health care. But, in my entire professional career, I’ve never met anyone who said they cared about having the choice of commercial insurance plans. To the contrary, they don’t like making that choice. The choice we all want is the choice of doctors and hospitals we want to use at an affordable price.

    Moreover, Harris fails to explain why private insurers will be any more accountable under her proposal than they are today–largely unaccountable. She does not seem to realize that Medicare Advantage plans, from their inception, have failed to comply with many of their contractual obligations, threatening the health and safety of their members; and, the federal government has lacked the power to punish them effectively, let alone to get them to comply with their legal obligations.

    Medicare Advantage plans can’t even manage to provide their enrollees with up-to-date provider directories. They engage in widespread denials of care and payment, according to the US Office of the Inspector General. And, they won’t turn over data, required by law, that would reveal the services they provide their members to allow an independent assessment as to whether they are meeting their members’ needs.

    Federal audits of Medicare Advantage plans have not helped to keep Medicare Advantage plans in line. Short of a provision in the law that either held Medicare Advantage CEO’s personally liable for failures to comply with the law or put them out of business for failing to comply, how exactly will Harris’ proposal induce them to behave properly? Or, is Harris prepared to call for these severe penalties?

    If not, what is she thinking? Other wealthy countries manage to guarantee health care to everyone at half the cost we pay, and they rely on private insurers. But, for the most part, their insurers are non-profit. And, the insurers are regulated like utilities. It feels like a fantasy to believe that our for-profit, shareholder-accountable, health insurers are going to behave any differently than they behave today. They have money and power, which they will continue to wield to make sure they can operate without accountability.

    In sum, 200 economists have united behind Sanders’ and Jayapal’s Medicare for All single-payer proposals because Medicare for All saves money and guarantees affordable health care to all. Harris’ health care reform proposal introduces new rules for private health plans without any meaningful cost savings or insurer accountability. Regardless of what Harris believes, her health reform proposal will not give people the affordable health care they want and need.

    Here’s more from Just Care: