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Reminders that Private Insurers Use Shady Tactics to Manipulate and Deceive Us

“Free” preventive services that cost patients hundreds of dollars. A Medicare enrollment “choice” that defaults to Medicare Advantage. These are two newly highlighted devious maneuvers that favor benefits for shareholders over benefits for the public.

February 8, 2024

Opinion: Ouch. That ‘free’ annual checkup might cost you. Here’s why.
Washington Post
January 24, 2024
By Elisabeth Rosenthal

When Kristy Uddin, 49, went in for her annual mammogram in Washington state last year, she assumed she would not incur a bill because the test is one of the many preventive measures guaranteed to be free to patients under the 2010 Affordable Care Act. The ACA’s provision made medical and economic sense, encouraging Americans to use screening tools that could nip medical problems in the bud and keep patients healthy.

So when a bill for $236 arrived, Uddin — an occupational therapist familiar with the health-care industry’s workings — complained to her insurer and the hospital. …

The ACA’s designers might have assumed that they had spelled out with sufficient clarity that millions of Americans would no longer have to pay for certain types of preventive care, including mammograms, colonoscopies and recommended vaccines, in addition to doctor visits to screen for disease. But the law’s authors didn’t reckon with America’s ever-creative medical billing juggernaut. …

[HJM: see the article for more examples of this “billing minefield”. And see also
The colonoscopies were free but the ‘surgical trays’ came with $600 price tags]

Republicans Are Planning to Totally Privatize Medicare — And Fast
Rolling Stone
February 5, 2024
By Andrew Perez

The right-wing policy agenda written for a new Donald Trump presidency would “greatly accelerate” efforts to privatize Medicare.

Last year, for the first time ever, a majority of Americans eligible for Medicare were on privatized Medicare Advantage plans. If Republicans win the presidential race this year, the push to fully privatize Medicare, the government health insurance program for seniors and people with disabilities, will only intensify.  

Conservative operatives have already sketched out what the GOP’s policy agenda would look like in the early days of a new Donald Trump presidency. As Rolling Stone has detailed, the proposed Project 2025 agenda is radically right-wing. One item buried in the 887-page blueprint has attracted little attention thus far, but would have a monumental impact on the health of America’s seniors and the future of one of America’s most popular social programs: a call to “make Medicare Advantage the default enrollment option” for people who are newly eligible for Medicare.  

Such a policy would hasten the end of the traditional Medicare program, as well as its foundational premise: that seniors can go to any doctor or provider they choose. The change would be a boon for private health insurers — which generate massive profits and growing portions of their revenues from Medicare Advantage plans — and further consolidate corporate control over the United States health care system.

Comment by: Jim Kahn

We know very well that the fundamental purpose of the private health insurance business is to make money for shareholders. HJM has highlighted the massive profits which are enhanced by high financial barriers to care and tens of billions of dollars in overcharges to public payers like Medicare.

Now we learn of two more startling examples of shady business tactics, present day and dystopian future.

1) Creative billing. A mandated benefit of the Affordable Care Act is free-to-the-patient preventive care. That is, insurers pay fully. But sometimes they don’t. It turns out that segmenting prevention services into pieces, or piling on non-prevention services, hits patients with hundreds of dollars in fees. Not free! Reminds me of the massive “convenience,” “processing,” and “delivery” fees imposed when renting or purchasing a car, buying concert tickets, or banking. Idiosyncratic provider billing confuses matters. But insurers have an incentive to be negligent – if they fail to assure that charges are appropriately bundled in a prevention package, it lowers their costs as some costs land with patients.

2) “Default Enrollment to Medicare Advantage”. This scheme is in the dystopian Project 2025 laid out by the MAGA GOP – a 920-page blueprint for far-right policy implementation if Trump wins in 2024. Buried deep in the text is the idea that the choice of traditional Medicare vs. Medicare Advantage should “default” to the latter. That is, unless new Medicare beneficiaries “opt out” of MA, they’re stuck with it, and with the MA problems (like financial barriers and narrow networks) which we’ve written about. How much does this matter? A lot – one academic review estimated a 27% shift, e.g., from 40% MA to 67% MA. The exact effect will depend on wording, and could be a lot more. This is “behavioral economics” – e.g., nudging actions through choice framing, wording, or visual layout. If in the interest of helping people (e.g., eat healthier), terrific. If in the interest of building profits for shareholders with public money, terrible.

We need a single, government payer. It will end complex billing rules and manipulations to increase insurer profits. It will turn health insurance into a public good optimizing public benefit.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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