Time to End the Medicare Advantage Scam ~~ Thom Hartman

https://hartmannreport.com/p/time-to-end-the-medicare-advantage

The simple solution to the Medicare Advantage problem is to kill off the program. It was just a Trojan horse to privatize Medicare

Thom Hartmann Sep 8 30 6

Image by Angelo Esslinger from Pixabay

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Over 100 Democratic lawmakers last week introduced legislation to lower the Medicare eligibility age to 60. There is one small problem that needs fixing, though: so-called “Medicare Advantage.”

This week my new book, The Hidden History of American Healthcare: Why Sickness Bankrupts You and Makes Others Insanely Rich is officially available in bookstores nationwide and online. Here’s a chapter excerpt I think you’ll find interesting, particularly after all those awful TV ads with former football and sitcom stars we’ve had to endure the past few years…

The “Advantage” War against Medicare

Medicare Advantage is a massive, trillion-dollar rip-off, of the federal government and of taxpayers, and of many of the people buying the so-called Advantage plans.

It’s also one of the most effective ways that insurance companies could try to kill Medicare For All, since about a third of all people who think they’re on Medicare are actually on these privatized plans instead.

Nearly from its beginning, Medicare has allowed private companies to offer plans that essentially compete with it, but they were an obscure corner of the market and didn’t really take off until the Bush administration and Republicans in Congress rolled out the Medicare Modernization Act of 2003. This was the GOP’s (and a few corporatist Democrats’) big chance to finally privatize Medicare, albeit one bite at a time.

That law created a brand known as Medicare Advantage under the Medicare Part C provision, and a year later it phased in what are known as risk-adjusted large-batch payments to insurance companies offering Advantage plans.

Medicare Advantage plans are not Medicare. They’re private health insurance most often offered by the big for-profit insurance companies (although some nonprofits participate, particularly the larger HMOs), and the rules they must live by are considerably looser than those for Medicare.

Even more consequential, they don’t get reimbursed directly on a person-by-person, procedure-by-procedure basis. Instead, every year, Advantage providers submit a summary to the federal government of the aggregate risk score of all their customers and, practically speaking, are paid in a massive lump sum.

The higher their risk score, the larger the payment. A plan with mostly very ill people in it will get much larger reimbursements than a plan with mostly healthy people. After all, the former will be costly to keep alive and healthy, while the latter won’t cost much at all.

Profit-seeking insurance companies, being the predators that they are, have found a number of ways to raise their risk scores without raising their expenses. The classical strategies of tying people to in-network providers, denying procedures routinely during first-pass authorization attempts, and having very high out-of-pocket caps are carried over from regular health insurance systems to keep costs low and profits high.

But with Medicare Advantage, the big insurance companies have invented a whole new way to rip us all off while padding their bottom lines.

For example, many Medicare Advantage plans promote an annual home visit by a nurse or physician’s assistant as a “benefit” of the plan. What the companies are doing, though, is trying to upcode their customers to make them seem sicker than they are to increase their overall Medicare reimbursement risk score.

“Heart failure,” for example, can be a severe and expensive condition to treat . . . or a barely perceptible tic on an EKG that represents little or no threat to a person for years or even decades. Depression is similarly variable; if it lasts less than two weeks, there’s no reimbursement; if it lasts longer than two weeks, it’s called a “major depressive episode” and rapidly jacks up a risk score.

The home health visits are designed more to look for illnesses or codings that can increase risk scores than to find conditions that require medical intervention. They’re so profitable that an entire industry has sprung up of companies that send nurses out on behalf of the smaller insurance companies.

In summer 2014, the Center for Public Integrity (CPI) published an in-depth investigative report titled Why Medicare Advantage Costs Taxpayers Billions More Than It Should.

They found, among other things, that one of the most common scams companies were running involved that very scoring of their customers as being sicker than they actually were, so that their reimbursements were way above the cost of caring for those people.

Here are a few quotes from the report:

• “Risk scores of Medicare Advantage patients rose sharply in plans in at least 1,000 counties nationwide between 2007 and 2011, boosting taxpayer costs by more than $36 billion over estimated costs for caring for patients in standard Medicare.”

• “In more than 200 of these counties, the cost of some Medicare Advantage plans was at least 25 percent higher than the cost of providing standard Medicare coverage.”

• The report documents how risk scores rose twice as fast for people who joined a Medicare Advantage health plan as for those who didn’t.

• Patients, the report lays out, never know how their health is rated because neither the health plan nor Medicare shares risk scores with them—and the process itself is so arcane and secretive that it remains unfathomable to many health professionals.

• “By 2009, government officials were estimating that just over 15 percent of total Medicare Advantage payments were inaccurate, about $12 billion that year.”

• Based on its own sampling of data from health plans, the report shows how CMS has estimated that faulty risk scores triggered nearly $70 billion in what officials deemed “improper” payments to Medicare Advantage plans from 2008 through 2013.

• CMS decided, according to the report, not to chase after overcharges from 2008 through 2010 even though the agency estimated through sampling that it made more than $32 billion in “improper” payments to Medicare Advantage plans over those three years. CMS did not explain its reasoning.

• The report documents how Medicare expects to pay the health plans more than $150 billion this year [2014, the year the study was published].

Companies are almost never nailed for these overcharges, and when they are, they usually pay back pennies on the dollar.

For example, when the Office of Inspector General, Health and Human Services (which oversees Medicare), audited six out of the hundreds of plans on the market in 2007, they found that just those six companies “had been overpaid by an estimated $650 million” for that one year. As the Center for Public Integrity states, “CMS settled five of the six audits for a total repayment of just over $1.3 million.”

The Centers for Medicare and Medicaid Services also, in 2012, decided to audit only 30 plans a year going forward. As CPI noted, “At that rate, it would take CMS more than 15 years to review the hundreds of Medicare Advantage contracts now in force.” And that’s 15 years to audit just one year’s activity!

Things haven’t improved since that 2014 investigative report from CPI. In September 2019, Senator Sherrod Brown of Ohio and five Democratic colleagues sent a letter to President Donald Trump’s CMS administrator, Seema Verma.

“The recent HHS Payment Accuracy Report exposes that taxpayers have overpaid Medicare Advantage plans more than $30 billion dollars over the last three years,” Brown wrote. “This report comes on the heels of a 2016 Government Accountability Office (GAO) report and a 2013 GAO report on [Medicare Advantage] plan overcharges and the failure of the Centers for Medicare and Medicaid (CMS) to recoup billions of dollars of improper payments from MA plans.”

Meanwhile, during the four years of the Trump administration, CMS went out of their way to illegally promote Medicare Advantage plans (which typically cost CMS far more than a regular Medicare plan).

A February 2020 report in the New York Times stated, “Under President Trump, some critics contend, the Centers for Medicare and Medicaid Services, which administers Medicare, has become a cheerleader for Advantage plans at the expense of original Medicare.”

The report pointed to the draft release of the 2019 Medicare & You handbook, which is mailed every year to all enrollees and posted online. “Advocates and some lawmakers criticized language describing Advantage as a less expensive alternative to original Medicare.”

The National Bureau of Economic Research (NBER) compared Medicare Advantage with traditional Medicare and found the Advantage programs to be mind-bogglingly profitable: “MA insurer revenues are 30 percent higher than their healthcare spending. Healthcare spending for enrollees in MA is 25 percent lower than for enrollees in [traditional Medicare] in the same county and [with the same] risk score.”

At the same time, Medicare Advantage often screws its customers. According to the NBER study, people with Medicare Advantage got 15 percent fewer colon cancer screening tests, 24 percent fewer diagnostic tests, and 38 percent fewer flu shots.

Speculation is rife as to why CMS would allow—much less promote—privatized plans that cost Medicare far more than original Medicare to rip off taxpayers to the tune of billions of dollars a month.

One possibility is regulatory capture—people working in CMS know that if they go along and get along, very well-paid jobs are waiting for them at for-profit insurance companies after a few years of government service. This is a chronic problem at other regulatory agencies, particularly those overseeing pollution, pharmaceuticals, telecommunications, and banking.

Another answer is that the Bush administration—where Medicare Advantage started—was so enamored of the idea of privatizing Medicare to eventually destroy the program (George W. Bush campaigned extensively from the late 1970s through his presidency to privatize both Social Security and Medicare) that they turned a blind eye to abuses.

The Obama administration had other priorities, as they were trying to push through the Affordable Care Act and didn’t want to upset the apple cart. And when Trump came into power, his folks saw anything that drained resources out of Medicare and into the pockets of multimillionaire health insurance executives—a group notoriously generous when it comes to making political contributions—as a plus.

You Are Locked in to Medicare Advantage

A fellow I’d known decades ago recently bubbled back into conversation among a few of us who’d hung out together in New York back in the 1970s. Sam, I’ll call him, had turned 65 and hadn’t had employer-provided health insurance in years. He spent a few hours trying to figure out how to sign up for Medicare and then gave up, totally confused, figuring he’d try again in a few months.

Unfortunately, his prostate intervened. When Sam started experiencing pain urinating, he visited a local “doc in a box” urgent care clinic, where they gave him a PSA test. The result was shocking: his PSA was so high that it was a virtual certainty he had prostate cancer, and possibly it had even metastasized, a situation that is the second-leading cause of cancer death in American men.

Telling him that he’d be facing hefty doctor and hospital bills regardless of the outcome, the urgent care clinic signed him up for a Medicare Advantage plan offered by an affiliate that almost certainly paid them a commission for the sign-up. Sam was excited, though, because he now had insurance, and it was a “no dollar” plan that didn’t cost him a penny.

Sam then got on the phone to find a urologist who specialized in cancer. He found that the best worked out of Memorial Sloan Kettering Cancer Center in New York, and, telling them he was “on Medicare,” he made an appointment to see one of their top docs. A month later, when his appointment finally opened up, the person who was checking him into the system told him that he’d have to pay cash because his Advantage plan didn’t include Sloan Kettering.

In fact, more than a third of all Medicare Advantage plans nationwide do not include any of the National Cancer Institute centers, and none of the Advantage plans offered in the New York City area include the nation’s most famous one, Memorial Sloan Kettering Cancer Center.

Shocked, Sam contacted Medicare to see if he could transfer from Medicare Advantage to regular Medicare. This all happened in fall 2020, so they told him that he could make the change during the “open enrollment period” of October 15 to December 7. He made the change and called Sloan Kettering back.

This time, they wanted to know what Medigap policy he’d signed up for to fill in the 20 percent of billing that Medicare doesn’t cover. That sent Sam back to the internet and, ultimately, to an insurance agent, who told him that while Medigap plans can’t refuse you because of preexisting conditions when you first sign up when you turn 65, if you shift from Medicare Advantage back to traditional Medicare after that first enrollment, particularly if you’re older or sick, they can simply refuse to cover you.

Reporter Mark Miller wrote for the New York Times in February 2020 about Ed Stein, a 72-year-old man with bladder cancer and a Medicare Advantage plan that didn’t cover the cancer docs in his area who specialized in his type of cancer. He tried to shift back to traditional Medicare to cover what promised to be complex and expensive surgery and chemotherapy. As Miller wrote, “That was when he ran up against one of the least understood implications of selecting Advantage when you enroll in Medicare: The decision is effectively irrevocable.”

As of this writing (November 2020), my friend Sam still hasn’t seen a doctor. This is the state of healthcare in America as it’s been sliced and diced by the multibillion-dollar insurance industry.

Meanwhile, every fall, Americans are inundated with hundreds of millions of dollars’ worth of TV, direct mail, and internet advertising for Medicare Advantage plans. And where does the money come from to pay for that advertising?

It comes from the same place that provided over $1 billion in wealth to the former CEO of United Healthcare, and over $100 million a month in compensation to senior executives in the largest health insurance companies: denying claims while collecting risk adjustment claims from your tax dollars and mine.

The simple solution to the Medicare Advantage problem is to kill off the program. It was just a Trojan horse to privatize Medicare, and its presence will make Medicare for All even harder to implement. At the same time, the 20 percent hole that the GOP insisted on for skin in the game with real Medicare needs to go, too.

A comprehensive Medicare for All program will eliminate both of these problems.

Roe v Wade died with barely a whimper. But that’s not all ~~ Laurence Tribe,

https://www.theguardian.com/commentisfree/2021/sep/02/roe-v-wade-texas-abortion-law-us-constitution

~~ posted for dmorista with introduction by dmorista ~~

Introduction:

As the U.S. reels from storms and floods in the East and wildfires in the West; as of midnight of August 31^st a new social assault was launched against the women of America by the ultra-right regime of Greg Abbot and his antediluvian allies in the Texas State Legislature. The American right-wing has long railed against any use of public funds or resources to help the poor of the society and/or to ameliorate the many injustices inflicted upon them. Now, however, as a legal stratagem to avoid court rulings that prevent state governments from enforcing clearly unconsitutional laws, the State of Texas has enacted a law that encourages vigilantes to file lawsuits against anybody who “aids or abets” a woman seeking an abortion after there is a “fetal heartbeat”. This is “privatization” carried out to an extreme never seen in the U.S. before, and inconceivable in most of the developed world.

Some legal analysts do not think that Texas can, or will, enforce the law on people assisting women to leave the state to obtain an abortion in another state. Lawrence Tribe, a law professor at Harvard disagrees. His reasoning on that issue as well as the other negative aspects of this type of social control strategy is discussed in the first article, from The Guardian, posted here. There has already been a 400% increase in women appearing at abortion clinics in neighboring states.

The American right-wing, lavishly supported by the ultra-right rich, has managed to set up a Supreme Court with a 6 – 3 majority that supports reactionary social policies, some of which only have about 15% support among the population, and none of which have majority support. However, the membership of the Supreme Court, that is currently at 9, is not set by the Constitution but is set by Congress by the passage of legislation. Also the Constitution does not mandate life-time terms for the members of either the Supreme Court or the “lower” courts. The number of justices on the Supreme Court has been changed 7 times during the history of the nation. The current situation is dire and certainly crosses the threshold for action of this sort. The Website, Demand Justice, discusses various issues of the U.S. Federal Court system. This post includes some thoughts they have about the Supreme Court.

Some who read and comment here at Leftist Politics might dismiss this as “useless reformism”. I do not agree, while I don't think efforts at these sorts of reforms should be the leading component of the efforts of leftists, we certainly should support these worthy efforts as carried out by the sort of people who concentrate their efforts on such initiatives.

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Article:

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For years, as the supreme court’s composition kept tilting right, reproductive rights have been squarely on the chopping block. Now they are on the auction block as well.

Observers have speculated how today’s new ultra-right court would commence the slicing: by chipping away slowly at Roe v Wade? Or by taking the political heat and overruling it outright? Few imagined that the court would let a statute everybody concedes is flagrantly unconstitutional under the legal regime of Roe not only go into effect without being judicially reviewed but become the centerpiece of a totally unique state scheme that puts a bounty of at least $10,000 on the head of every woman who is or might be pregnant.

It wasn’t just Roe that died at midnight on 1 September with barely a whimper, let alone a bang. It was the principle that nobody’s constitutional rights should be put on sale for purchase by anyone who can find an informant or helper to turn in whoever might be trying to exercise those rights.

That, after all, is how the new Texas law works. Its perverse structure, which delegates to private individuals anywhere a power the state of Texas is forbidden to exercise itself until Roe is overruled, punishes even the slightest form of assistance to desperate pregnant women. Doctors, family members, insurance companies, even Uber drivers, are all at risk if they help a woman in need. And the risk is magnified by the offer of a big fat financial reward for whoever successfully nabs a person guilty of facilitating an abortion once a heartbeat can be detected, typically six weeks after a woman’s last period, well before most women even know they are pregnant. There is not even an exception for pregnancies resulting from rape or incest. No law remotely like this has ever been allowed to go into effect.

The prospect of hefty bounties will breed a system of profit-seeking, Soviet-style informing on friends and neighbors. These vigilantes will sue medical distributors of IUDs and morning-after pills, as well as insurance companies. These companies, in turn, will stop offering reproductive healthcare in Texas. As of a minute before midnight on 31 August, clinics in Texas were already turning patients away out of fear. Even if the law is eventually struck down, many will probably close anyway.

Worse still, if women try to escape the state to access abortion services, their families will be on the hook for offering even the smallest aid. If friends or family of a woman hoping to terminate her pregnancy drive her across state lines, or help her organize money for a plane or bus ticket, they could be liable for “aiding and abetting” a now-banned abortion, even if the procedure itself takes place outside Texas.

Adding insult to injury, if a young woman asks for money for a bus ticket, or a ride to the airport, friends and parents fearful of liability might vigorously interrogate her about her intentions. This nightmarish state of affairs burdens yet another fundamental constitutional privilege: the right to interstate travel, recognized by the supreme court in 1999 as a core privilege of federal citizenship. Welcome to Gilead!

Many wealthy women will presumably still find ways to access care. But their poor, disproportionately minority sisters will be stuck, forced to face down the barrel of unimaginably cruel choices. Desperate women will still seek abortions but will be forced to do so on the black market and in back alleys. Fewer Samaritans will risk heavy fines or imprisonment to help them. Some will die trying.

What can be done? We can give up on this court and try pressuring Congress to pass the Women’s Health Protection Act, which would enshrine a federal statutory right to provide and receive abortion care free of these sorts of state schemes. But such a bill would die at the hands of Mitch McConnell, the minority leader, in a Senate filibuster.

And what if it were somehow to pass? Odds are that a court majority, despite having held that Congress is empowered to enact a nationwide ban on certain late-term abortions because medical procedures are part of interstate commerce, would suddenly “discover” new limits on the reach of the commerce clause as a source of congressional power and strike the act down. When the court so casually lets a law that flouts its precedents take effect, all bets are off.

Or are they? Maybe even justices deeply hostile to abortion rights can be persuaded to balk specifically at the unprecedented financial incentives this grotesque law creates to put a price on the head of every pregnant woman or girl. Shades of sex slavery and prostitution might put this privatization of law enforcement in a light even conservative jurists find unbearable. What if women chilled by this business model, or those seeking to help them to avoid unwanted motherhood, were to sue the Texas authorities who stand ready to disburse $10,000 bounties for each forbidden abortion detected or prevented?

As Justice Sotomayor said in her dissent – there were four dissents in all – the Texas law “is a breathtaking act of defiance – of the constitution, of this court’s precedents, and of the rights of women seeking abortions throughout Texas”. After a puzzling silence of a day and night, “the court finally [told] the Nation that it declined to act because, in short, the State’s gambit worked.” Even if not a single justice in the 5-4 majority rejects the ability of a state to “evade federal judicial scrutiny by outsourcing the enforcement of unconstitutional laws to its citizenry”, and even if all five of the justices in that majority stand ready to trash Roe v Wade, maybe at least one of those justices would agree that no state can hand out financial rewards to people – not only citizens in Texas but people from anywhere in the country, perhaps the world – shredding the constitution of the United States?

At least it’s worth a try.

• Laurence H Tribe is the Carl M Loeb University professor and professor of constitutional law emeritus at Harvard University and an accomplished supreme court advocate. Follow him on Twitter @Tribelaw

Various suggestions for action by a reformist website:

Demand Justice at < Reform the Supreme Court: Demand Justice is leading the fight >

Our courts are in crisis

With a 6-3 Republican supermajority, the Supreme Court is too biased in favor of special interests and Republican politicians. Our democracy is at risk from decisions that suppress the right to vote.

Adding four seats is the solution—and we need your help to get it done. Congress can change the number of justices on the Court at any time with a simple piece of legislation, and it has done so many times throughout American history. Now, top Democrats have introduced a bill to add seats and restore balance. We need your help to get enough votes to make this bill a law.

Have questions about what it means to expand the court and why now is the time to get it done?

Frequently Asked Questions:

Why do we need to reform the Supreme Court?

We need to restore balance to the Supreme Court. With a 6-3 Republican supermajority, the Court is deciding cases in a consistently partisan, anti-democracy, pro-corporate direction. We need a Court that better reflects the whole country, not just special interests and the Republican Party.

To see how far tilted in one direction the Court is right now, you just need to look at what it’s been doing to our democracy. The Republican-appointed justices have opened the floodgates to unlimited spending in elections in cases like Citizens United, gutted the Voting Rights Act, and allowed partisan gerrymandering that benefits Republican politicians and special interests. We have to restore balance.

Why is adding seats the right solution?

Adding four seats is the only way to restore balance to the Court immediately. Adding seats to the Court is straight-forward, constitutional, and grounded in history. All it takes is a bill passed through Congress and signed by the president. And there’s nothing new about the idea of adding seats to the Supreme Court. The framers left it to Congress to decide how many justices sit on the Court, and Congress has changed the number of justices six times throughout history.

Where do things stand right now?

Reps. Hank Johnson, Jerry Nadler, and Mondaire Jones and Sen. Ed Markey have introduced a game-changing bill. Now we have to build a grassroots movement to win 218 votes to pass this bill in the House and 51 votes in the Senate. We have a once-in-a-generation, two-year window to pass this bill while Democrats control the House, Senate, and presidency.

We need to pressure every Democratic House member and senator to publicly announce their support for this legislation. We’ll do that by calling their offices, requesting constituent meetings, showing up at public events, writing letters to the editor, and taking other steps to blitz them with proof of how wide and deep the support is for this legislation. We must make these Democrats understand the urgency of cosponsoring this bill.

How does the fight for Court reform relate to other democracy reforms in the news?

As you have probably seen, there is a major effort among Democrats in Congress right now to pass democracy reform bills like HR 1 and the John Lewis Voting Rights Act. We believe all these bills are quite likely to pass in the course of the next year, with growing support for filibuster reform among top Democrats who had previously resisted it.

Our goal is to make the Judiciary Act part of this package of must-pass democracy reforms, and to pass it with 51 votes in the Senate just like we think will eventually happen with HR 1, the John Lewis Voting Rights Act and DC statehood. The rationale is clear: unless we reform the Court, all of these other proposals will be gutted by the Republican-appointed justices.

Can we really get this done?

Yes. The work ahead of us will not be easy, but we have the wind at our back. Support for adding seats to the Court has never been higher. The rush by Republicans to fill Ruth Bader Ginsburg’s seat last year produced a wave of support for this idea, and we picked up support from more than a dozen lawmakers like AOC to Ilhan Omar to Barbara Lee. Former Attorney General Eric Holder has announced his support. Alex Padilla, California’s newest senator who was picked to succeed Kamala Harris, announced he supports Court expansion before he was even sworn in. When Tom Cotton forced a vote in the Senate to try to make it harder to change the Court’s size, all 50 Senate Democrats voted together to keep the option of expanding the Court on the table. President Biden has announced a commission to study reforms, which is a sign that everyone now recognizes something must be done.

Much like the filibuster, Court reform is an idea that meets with initial resistance from people who have spent a lot of time in Washington but that will grow in support as people hear from the grassroots about why we clearly need it to save our democracy.  

To convince Nancy Pelosi to bring this bill up for a vote on the floor, and Chuck Schumer to bring it up in the Senate, we need to show it will have the support of all Democrats. That’s why the first step is pressuring Democratic House members and senators to announce they will co-sponsor the Judiciary Act. That is the task in front of us–and we need all of you to make it happen

Medicare for ALL ~~ Article by Natalie Shure

https://portside.org/2021-07-27/well-never-fix-hospitals-price-gouging-if-we-dont-break-their-stranglehold-congress

M4A

Rather than force hospitals to be up front with patients about their costs, we should strip them of the power to set them.

We’ll Never Fix Hospitals’ Price Gouging If We Don’t Break Their Stranglehold on Congress

, Apu Gomes/Getty Images

Nearly every hospital in the United States appears to be flouting Trump-era rules mandating price transparency, according to a bombshell new study. Put into effect on January 1 under the Trump administration, the new directive requires hospitals to make rates they negotiate with different insurers for procedures publicly available—a move proponents argue curbs runaway health care costs by stripping hospitals of the market-hobbling opacity that’s long benefited their bottom lines. The new research published by the nonprofit group Patient Rights Advocate determined that 471 of 500 hospitals examined were not in compliance with the new rule, results even more shocking than a previous study in the Journal of the American Medical Association estimating a mere 80 percent of hospitals to be in violation. The Biden administration recently directed the Department of Health and Human Services to enforce the rule as part of his extensive executive order aimed toward facilitating market competition.

It’s worth emphasizing just how conservative this line of thinking is: Not only does the fetishization of price transparency endorse the idea of health care as a market good, it also embraces a vision of patients as consumers, saddled with the arduous task of dutiful comparison shopping whenever they require care. Never mind that the path to universal health care in practically every country that has it relies heavily on public sector financing and coordination, instead of an optimized marketplace.

The price transparency policy was largely pushed by Cynthia Fisher, a Republican donor who convinced Donald Trump to enact the rule. Her goal is not just to reduce prices but to stand as a bulwark against more far-reaching change. In an interview last year with Morning Consult, she said, “This is a shape-shifting moment—we’re at this inflection point.… It is probably the last moment of time for transparency, or we go to Medicare for All.” But Medicare for All, not a piecemeal market-based approach, is the only way significantly to reduce America’s uniquely high medical bills.

Though insurers are often the most villainized part of the system, hospitals shoulder plenty of blame for our health care catastrophe. Hospitals gobble up almost a third of our national health care spending, topping $1 trillion annually. The American Hospital Association is one of the most formidable trade groups on Capitol Hill and has been a fierce opponent of not only single-payer but the public option and other watered-down reforms, as well. In most cases, it’s safe to say that hospitals have the upper hand over insurers when it comes to reimbursement negotiations, particularly when they consolidate or otherwise dominate a given geographical area.

The sums that hospitals are able to extract from payers have been widely lambasted as both astronomical and irrational, differing by tens of thousands within the same hospital or for the same procedure, depending on a patient’s insurance plan. In extreme cases, hospitals have come after their own patients with lawsuits to recoup medical debt, roping them into ruinous repayment plans for years after their treatments. In short, hospitals are so unsympathetic that critics frequently chide left-of-center health care commentators for going easy on them compared to insurers, implicitly echoing the conclusions invoked by the title of the legendary 2003 paper by health economist Uwe Reinhardt that health care costs are largely driven by hospitals’ eye-popping reimbursement rates: “It’s the prices, stupid.”

But what if the problem is the existence of “prices” at all? Why do we talk about the “price” of an appendectomy and a blood transfusion but not about the “price” of one 40-minute math lesson for a fifth grader and a half-hour of detention after school? In the U.S. health care system, the “price” of a given service is the amount a given facility gets reimbursed for it by the patient’s payer—amounts that differ wildly depending on a variety of factors. As historian Gabe Winant chronicled in his book The Next Shift: the Fall of Industry and the Rise of Healthcare in Rust Belt America, the 1980s switch from calculating reimbursement by length of patients’ stay to the “price” of care received only served to spur the corporatization of hospitals by rewarding capital-intensive high-tech and invasive care over the services offered in simpler community hospitals—empowering the bigwigs to bill for more high-cost procedures and snap up the smaller players that couldn’t. This gave large hospital chains even more market power to break the backs of whatever insurer tries to argue with them.

But the problem with that dynamic isn’t “prices,” it’s power—a problem that price transparency does little to solve. To borrow Winant’s example, it’s tough to imagine Pittsburgh insurers holding onto too many customers were they to decide not to include University of Pittsburgh Medical Center in their networks, suggesting that listing negotiated prices could only apply so much downward pressure through competition. But even in a perfect world, transparency still wouldn’t offer much in the way of patient relief: Most hospital visits entail thousands of dollars’ worth of care even when coherently priced, so a slight reduction would leave most patients with roughly similar out-of-pocket expenses, even if their insurers save a bit on so-called “medical loss.” Framing that as a boon for health care “consumers”—a ghastly phrase the proponents of this scheme sure do seem to love!— is disingenuous at best.

Medicare for All, on the other hand, wouldn’t just obliterate health insurance as we know it, it would upend hospitals’ ability to bilk payers and patients in the process. With private insurers barred from selling plans that duplicate the benefits of the single public pool, and with providers barred from taking cash for procedures covered by Medicare, hospitals lose the privileged position they enjoy over a fractured field of insurers whose existence—unlike hospitals—provides us exactly nothing of value. The vision outlined in Representative Pramila Jayapal’s House bill essentially transcends the concept of “prices” at all, allocating each hospital a global operating budget akin to a fire department or school. Medicare for All would also impart strict control over profits and capital expansion: Hospitals wouldn’t be permitted to keep or reinvest surplus revenue, or beef up facilities without public approval, rendering it all but impossible for them to keep taking cues from corporate playbooks.

As we move toward the more just hospitals of the future, we deserve to aim beyond a tedious master list of prices. The Biden administration is struggling to get hospitals to disclose their prices, but this is fighting the battle the wrong way around. Instead, it should be looking for a way to kneecap the power of hospitals to set them in the first place. Scrapping private insurance is the best way to do it.

SANDINISTA NICARAGUA, MORE DIGNIFIED AND VICTORIOUS THAN EVER By Carlos Fonseca Terán,

https://popularresistance.org/sandinista-nicaragua-more-dignified-and-victorious-than-ever/

~~ posted for dmorista ~~

Nicaragua Is In The News Again.

But Not For Being One Of The Countries With The Greatest Reduction In Poverty And Social Inequality Worldwide Since 2007 (Poverty By Half, Extreme Poverty By A Third, And Going From Being The Fourth Most Unequal Country To Being The Fourth Least Unequal In Latin America).

Nor is Nicaragua news for being the country with the highest level of direct ownership of the means of production by the working class in the Western Hemisphere (more than 50% of GDP and nearly 80% of economic units); nor for being one of the countries in the world that has most reduced illiteracy in the same period of time (from 35% to 3%); or for being one of the countries with the largest increase in per capita investment in health (from U$32 to U$70) and with the largest reduction in infant mortality (from 29 to 11.4 per 1,000 live births).

Nicaragua is not news for being the country in the world that has most reduced the gender gap (from 90th to 12th), the country with the highest presence of women in its cabinet (58.82%), as well as having the fourth highest presence of women in the legislative branch (48.4%) and being the country that most radically applies the criterion of gender equity across its social policies.

Nor is this country in the news for being among the countries that have most increased electricity coverage (from 53% to 99%) and the one that has most increased its renewable energy sources (from 2% to 90%); nor for being the safest country in Central America and one of the safest in Latin America (with a rate of 3.5 homicides per year per 100,000 inhabitants, Costa Rica being the closest with 11.2); nor is Nicaragua news for having one of the governments in the world with the highest sustained popular support for the longest period of time (with rates around 60% in the last eleven years, almost uninterruptedly).

But it is not for any of these achievements that Nicaragua has once again become newsworthy, but because it has applied its laws in a sovereign way, the most recent of these laws having been approved by an overwhelming majority of the people’s representatives in the legislature and under which the relevant authorities, using their legitimate powers and fulfilling their constitutional duty, have ordered the arrest of various individuals (nineteen at the time of writing) for one or other of the following crimes:

• Actions publicly declared and undertaken by almost all those who have been arrested, aimed at achieving the imposition against Nicaraguan institutions and citizens of unilateral coercive measures by a hostile foreign power, the United States, with the purpose of boycotting public administration and the application of State policies, including the implementation of social programs thanks to which Nicaragua has reached the indices mentioned above via its model of social transformation and improvement in the living conditions of the great majority of its citizens.
• Conspiracy to destabilize the country, in the service of that foreign power, the United States, through the implementation of terrorism and violent actions in general.
• Money laundering in the financial operations of the “Violeta Barrios de Chamorro” Foundation, which also financed journalists, “political analysts” and writers (all of them claiming to be “independent”) with money coming from agencies known for their role in destabilizing governments not aligned with the interests of the United States, some of those agencies being the US government bodies like USAID and NED, but also others like the Soros foundations, and also European agencies such as OXFAM. That funding has been acknowledged by the people concerned. It is worth noting that when Nicaragua’s Foreign Agents Law was created, which obliges those who receive donations from other countries to report them and inform about their final use, this foundation formally closed its operations to evade complying with the law, in spite of which it continued receiving funds from the foreign agencies cited above as well as others. The specific operations of this criminal network are still under investigation by the competent authorities, who will explain the results of the investigation in due course.
• Serious anomalies in the administration by a banking entity of financial resources used to support illicit activities linked to finance from the aforementioned agencies.

Nicaragua is not obliged to justify to foreigners what it does or does not do in full and legitimate exercise of its sovereignty and self-determination, and in the defense of those principles, but in the face of the campaign of lies against the country that flood the news media daily, it is right and proper to defend it, just as the Sandinista Revolution has the right and duty to defend itself in any context, including of course, the battle of ideas.

The laws being applied by the Nicaraguan authorities to the people detained and who are receiving due process in accordance with the current legal norms, are similar to those that exist in most countries whose governments, brazen in their interference, have condemned the approval and application of those laws in Nicaragua for crimes committed after their entry into force, not for crimes prior to their entry into force, but for crimes committed subsequently, in compliance with the principle of laws being non-retroactive since the illegalities and crimes committed and promoted by most of these people during the attempted coup d’état in 2018 have already been judged, and for which those convicted were subsequently granted pardon, for the sake of peace and stability of the country.

When we talk about the crimes committed in 2018, during the coup attempt, they include murder and other crimes that caused dozens of deaths of Nicaraguans, about which it is worth remembering that, of the total of something over two hundred dead caused by the coup attempt, most of them were Sandinistas, of which, in turn, the majority died as a result of cold-blooded murders, after being kidnapped and subjected to torture, many of them documented by the perpetrators themselves in videos, circulated in social media, while in contrast, all the deaths in the opposition ranks were the result of street fighting, generally provoked by them.

But that atmosphere of instability and chaos lasted just three months (from April 18th to July 18th 2018), because the country very soon recovered tranquility and peace, thanks to the massive and organized participation of the people defending their nation and their revolution, as also happened during the war of aggression imposed on Nicaragua by Ronald Reagan’s government  in the 1980s, in which the Sandinista Revolution was also victorious, although in that case only after several years of intense struggle.

Turning now to the current situation, as is well known, at different times some of those recently detained by the Nicaraguan authorities had expressed presidential aspirations in the context of the upcoming elections to be held on November 7 of this year. Specifically, of the nineteen against whom an arrest warrant has been issued and of which there are seventeen under arrest, five had expressed that they wanted to run for the presidency, and two of them had submitted requests to the political party of their choice to do so, but there are six other presidential aspirants among the extreme right wing coup plotters, who are at liberty and for whom no arrest warrant has been issued and no indictment has been initiated; of them, there are also two who have submitted requests to be considered as presidential candidates by the political party of their choice. Not to mention the other sectors of the right wing that are likely participate in the elections.

The presence of presidential aspirants among those detained has led detractors of Nicaragua’s Sandinista government to argue, abandoning all logic, that the investigative processes and the arrests made out are irrational, given that they self-evidently harm the political image of the government. That is to say, according to these “analysts”, presidential aspirations should endow impunity and even worse, that the impunity should result from the government acting out of political convenience, obstructing the relevant institutions from fulfilling their role and applying the relevant legal norms, in strict compliance with the rule of law. In one opinion article, the writer even appeared scandalized because one of those implicated as a beneficiary of funding from the aforementioned agencies, who is not under arrest and was only called to testify before the Public Prosecutor’s Office, is a winner of the Cervantes Literature Prize, as if this were a license to commit crimes.

Yes, it is indeed the case, from the electoral perspective, that the application of the law to these individuals has a political cost for Sandinismo, but the institutions of the Nicaraguan State would be very wrong to act on the basis of political criteria derived from electoral calculations, since the country’s self-determination and sovereignty are imperative and are, moreover, inalienable principles of Sandinismo. This should serve as a lesson to the demagogues who spend their lives demanding that Nicaragua respect the rule of law and the subordination of institutions to the established legal order. This is, furthermore, the best demonstration that the reason for the arrests are not because the people concerned are political opponents or because they have aspirations to the presidency of the Republic.

Moreover, in all the opinion polls, including those conducted by the opposition, none of those detained even comes close to having the popular support of Sandinismo and in particular, the level of popular support for the President of the Republic, Comandante Daniel Ortega Saavedra, thus confirming that the arrests have been made using the strictest and most transparent application of the laws that govern the Nicaraguan State. And it is worth reiterating that these laws are very similar to those in force in the very same countries whose governments have condemned Nicaragua for the arrests.

A situation of particular concern in some sectors outside Nicaragua, in certain cases due to disinformation and in others due to lack of political awareness, has been that among the nineteen individuals against whom arrest warrants have been issued of whom seventeen have been detained, six of them belong to a political group created in the nineties by former Sandinistas, and among these six are three who held high positions in the Sandinista government of the 1980s and participated in the liberation war against the Somoza dictatorship.

First of all, it should be clear that none of that history should be a reason for impunity for anyone, but in the case of the former Sandinistas, the fact that they are no longer Sandinistas is not the reason for their arrest, since it does not constitute a crime, unlike treason which is one of the crimes for which they have been arrested, as is the case with the other people under arrest, all on the strictest legal basis. But there are things that very few people know among the ranks of the international Left outside Nicaragua, and this makes some people defend the individuals mentioned here as if they were the same revolutionaries they were earlier in their careers, and nothing is further from the truth.

These former Sandinistas joined the right wing early in the 1990s, when, while still militants of the FSLN, they publicly renounced socialism, anti-imperialism, the popular struggle and the vanguard character of the FSLN. In the end, they were defeated internally in the FSLN’s Extraordinary Congress of May 1994 and they chose to abandon the FSLN and found a party in which they continued calling themselves Sandinistas, and which they also finally ended up renouncing, as was to be expected. Such that those people who continue to call them Sandinistas, if they are so fond of them, should respect them a little more and not call them something they themselves now reject. By the way, one of the individuals detained, of those who were linked to the Revolution and then took the path of the right, a while ago complained, using a good Nicaraguan term, that the name “Sandinista” caused her revulsion. So their admirers should think twice before continuing to describe them in that way.

It would take far too long and, anyway, is beyond the scope of this article to narrate here the history of this betrayal of Sandinismo. But it is worth mentioning some fundamental facts. Although these people were a minority in the FSLN Congress in 1994, since they were also a minority in the party’s rank and file, they were nevertheless a majority among those who had held senior government and party posts in the 1980s. They were also a majority among those who had been elected to the legislature in the 1990 elections, so they exploited these advantages and shortly after the defeat suffered by Sandinismo in those elections they appropriated the material patrimony of the FSLN, and then in 1995 proceeded to reform the Constitution via a pact with the right wing. As a result, they eliminated the right to free health care and education, legitimized the privatization of public services, created a second round of voting so as to prevent the FSLN from winning the elections and imposed limits on presidential re-election to prevent Comandante Daniel Ortega from running again as a candidate, and they even established the qualified vote to elect magistrates in the different institutions, with the hope that they themselves might be elected.

But after the disastrous electoral results of 1996 for the parties promoting those reforms, the only way to secure a qualified vote, a requirement imposed by those same parties to elect the positions in question, was an agreement between the two main parties of the time, the FSLN and the PLC, which the ex Sandinistas manipulated to accuse the FSLN of doing exactly what they themselves had already done when no law obliged them to do so, namely make a pact with the right wing, in their case for purposes harmful to the people’s interests. But nothing they did then compares to what the ex Sandinistas would end up doing in the elections of 2008, 2011, 2012 and 2016, when they supported candidates of Nicaragua’s most recalcitrant and fundamentalist right wing, which had the support of the United States. It is as if, for example, in Argentina, former guerrillas who had fought against the military dictatorships in that country had supported Macri in the presidential elections there, or as if in Chile they had supported Piñera, or in Brazil Bolsonaro.

The political parties that made the constitutional reforms of 1995, among them the ex Sandinistas recycled as an upstart right wing, consulted no one, not even even for the sake of appearances. In the following year’s elections, all together they did not even receive 10% of the vote, which made evident the illegitimate and spurious character of their reforms. All this in spite of the fact that by having control of the electoral power, they blocked, in a self-evidently arbitrary way, any candidate who hindered their plans in those elections, something they forget when they accuse Sandinismo of sectarian abuse of the State institutions, since from their point of view only the right wing are impartial and transparent, when it controls those institutions. A curious fact is that the ex Sandinistas in question were even allies of the FSLN as part of the National Convergence political alliance in the local elections of 2000 and 2004, and also in the national elections of 2001, until they ran again on their own account in the national elections of 2006.

But the final definitive validation of these ex Sandinistas as counterrevolutionaries with no possible redemption was the failed coup attempt in 2018, when they united with pro-imperialist forces and led the armed counterrevolutionary actions that took place between April and July of that year. These individuals, who in the 1990s had already renounced the red and black flag, in 2018 accompanied the neo-Somocista hordes that repeatedly burned that revolutionary symbol, as also happened with the desecration of monuments and even the tombs of Heroes and Martyrs of the Revolution. One more expression of the levels to which these people had already descended by then, was their participation in meetings with individuals like Ileana Ros-Lehtinen and Marco Rubio, from whom they received support, as the coup plotters did in general from Álvaro Uribe, with whom they proudly took pictures, and from Jair Bolsonaro, who, making a fool of himself in the way only he knows how to do, offered Brazilian territory to prosecute the Sandinistas.

The café lounge pseudo-Left, which loves to join in the declarations of the imperialist powers against the Sandinista government, has long reproached the ruling Sandinistas in Nicaragua for an alleged alliance with private business leaders and the Catholic Church. Regarding the former, in Nicaragua, since Sandinismo returned to government, the percentage of GDP produced by means of production under associative, cooperative, family and community ownership went from less than 40% to more than 50%, to the detriment of traditional private enterprise, which saw its economic importance decrease from more than 60% to less than 50% of GDP, and in the first nine of the fourteen years that Sandinismo has been in government since 2007, the minimum wage of workers increased ten times more than in the seventeen neoliberal years. This is hardly favorable to the interests of private capitalist enterprise.

When it first came to power in 1979, Sandinismo offered private enterprise a framework of understanding and consensus for the sake of the country’s stability, but since at that time solidarity with the Sandinista Revolution was in vogue, the characteristic snobbery of the café lounge Left did not allow it to accuse Sandinismo at that time of seeking alliances with business people, who in the end back then did not accept the offer of coexistence, as they did when Sandinismo returned to power in 2007. Then, for some years, big business had no other option but pragmatism. However, after some time, at the first opportunity that presented itself and as is to be expected when there are contradictions between antagonistic interests, private business lashed out against the Sandinista government and, together with the hierarchy of the Catholic Church, was among the most aggressive sectors during the 2018 coup attempt, curiously enough with the support of all those people outside Nicaragua who accused Sandinismo of being allied with them.

As for the alleged alliance of the FSLN with the Catholic hierarchy, this is a kind of worldwide urban myth. There has not been a single day since Sandinismo returned to government in 2007, as there was not before, of course, in which Nicaragua’s Catholic Church leaders have not uttered all kinds of attacks against Sandinismo. The myth of this false alliance stems from the rapprochement that Cardinal Miguel Obando y Bravo made with Sandinismo during the last years of his life, but that rapprochement cost him precisely the support of the Vatican, so that as soon as he gave the first signs of reconciliation with Sandinismo, Cardinal Obando fell foul of Nicaragua’s Catholic Church hierarchy. There are also sectors on the Left whose problem is simply not having the infallible compass of anti-imperialism. That is to say, when one lacks direct knowledge of the situation of a country, it is enough to see which side the Empire and its disinformation media are on in order to at least have the ability to give the benefit of the doubt .

In Nicaragua the term “puchito” is popularly used as a synonym for little, and partly for that reason the coup leaders are known as “los puchos”, but the use of the term “pucho” in this case, has a connotation that is applicable beyond a quantitative sense, to allude to those who have no vocation for power, despite the fact that they have exercised it for so long. In Nicaragua, the bourgeoisie seems to have lost its instinct for power as a social class, an unusual phenomenon, but symptomatic of a true revolution.

At the world level, however, unfortunately, there is also an abundance of what one might call the “pucho Left”, that is, those self-styled Leftist sectors, which are stumbling around disoriented in the world or even in their respective national situations, without a compass to guide them, not just because they are a minority, but because they have not matured enough politically or worse, because they have started rotting away at some point in their erratic wandering. That Left which instead of denouncing imperialist interference, instead of attacking the common enemy of those who are supposed to fight for systemic change at a global level, and that in addition, despite their own impotent inaction, presume to judge who is revolutionary and who is not, or which revolution is a true one and which revolution is not, should make their own revolution so as to be able to preach by example and earn the moral authority to speak in the way they do.

But the coup right wing in Nicaragua is also puchito because it has no life of its own. It is a right wing on life-support provided by its imperialist owners. And it is not the fault of Sandinismo that the puchito right wing is led by confessed traitors to the nation, who would also be in jail in any self-respecting country. They are money launderers and even drug traffickers, like some others who were arrested some years earlier, not for the other crimes they had also committed, about which some of them even publicly boasted in messages broadcast in widely disseminated videos, and for which they had already been pardoned before, but in these other cases for common crimes very appropriate to their questionable moral condition, although now they seek to present themselves as political prisoners.

Finally, the strength of the coup-mongering right wing in Nicaragua is evident when, despite its most visible spokesmen being arrested for their misdeeds, not for their presidential aspirations or for simply being opposition, the most absolute calm prevails in the country. Life continues its course in the most serene atmosphere of peace imaginable, and not even the self same puchos interrupt their normal routine or even their recreational activities. If the arrested criminals were really political leaders, the situation would be very different. In 2018, when the coup plotters followed the orders of the interventionist imperialist agencies, they manipulated many people via psychological warfare using it as a component of the new coup d’état format designed by their imperial owners. Back then they wasted no time asking for permission to take to the streets.

But while it is easier to manipulate people than it is to convince him they are being manipulated, when they do finally become aware of the deception they have suffered then it is very difficult to manipulate them again. And that is what happens when the new psychological warfare coup formats fail. They will never again snatch from the Nicaraguan people the peace that has cost them so much nor the only true peace of social justice and freedom it makes possible.

Just as it is true that happiness can only be achieved when certain ethical values prevail and which overall in society can only predominate as the product and fundamental content of its revolutionary transformation. That kind of change is the only one from which the new Nicaragua under construction could emerge and from which it is emerging, with Sandinismo at the forefront, in permanent rebellion and victorious resistance against the world power of imperialism. And that itself is part of a long tradition of struggle dating from even before the mid-nineteenth century, when Nicaraguan and Central American forces defeated the filibuster troops sponsored by southern United States slave-owners; passing through the expulsion of the occupying US troops by General Augusto C. Sandino in the 1930’s; the overthrow in 1979 of the Somoza dictatorship imposed by the United States after the assassination of Sandino; the victory against the war of aggression imposed by the US government in the 1980s, and then against the neoliberalism imposed by electoral blackmail in the 1990s and following years, and finally against the attempted coup d’état in 2018. The tradition includes all the new victories that are being added in this struggle, one of whose fundamental objectives is, as Carlos Fonseca, whose birthday is commemorated today, declared: “A change of system, the overthrow of the exploiting classes and the victory of the exploited classes”.

In other words, the Sandinista government is popular rebellion in power, fighting from the government against the age-old system imposed by the oppressor classes; and as Ricardo Morales Avilés said, for this struggle to bear fruit “so many things must be changed … first power, property, ourselves, and then… fresh air and maize for everyone; fresh air and flowers for all”. This is what Sandinista Nicaragua is committed to achieving, today more dignified and victorious than ever.