Project 2025 Health Policy Critique Redux

August 15, 2024

Private Health Insurance

Project 2025: Promote direct primary care (DPC) by using health savings accounts (HSAs).
      What it means: Pay DPC doctors via HSAs set up with high deductible insurance.
      Why it’s bad: HSAs favor the healthy and wealthy, shifting unused funds to tax-free retirement accounts. This diverts money from health care to cushy retirements. (DPC itself is good: fosters continuity of the patient-doctor relationship and a focus on clinical care.)
       What we need: Don’t let DPC serve as an excuse to shift more HSA health care money into the pockets of wealthy retirees. Single payer would provide everyone with insurance for primary care along the line of DPC (and specialists, and all other care), and would grow the primary care work force. Funds not used for primary care would go to other health care needs.

Project 2025: End Affordable Care Act (ACA) regulation of private health insurance.
What it means: Repeal ACA rules that: protect access to insurance (guaranteed issue); require community-rated premiums (sick individuals pay the same as everyone); assure broad benefits; and prohibit revoking insurance based on trivial errors when applying (recission). Also end restrictions on short-term insurance and health reimbursement / savings accounts.
Why it’s bad: ACA rules make private health insurance much fairer and dependable, by assuring reliable broad coverage without discriminating against individuals with pre-existing illness. Removing the rules would hurt everyone, especially the sick.
What we need: Single payer would provide identical, comprehensive health coverage to everyone, progressively financed. Meantime, keep private insurance effective and fair.

Project 2025: Use a “truth-in-advertising” approach to handle surprise medical bills.
What it means: Replace formal dispute resolution with an approach that relies on publicly stated prices.
Why it’s bad: The “No Surprises Act” payment resolution process has too much ambiguity and thus disputes. But “truth-in-advertising” won’t work: patients in emergency and high stakes medical situations can’t consider or act on complex price disclosures, and such disclosures will often be incorrect or misleading.
What we need: A system where all care is covered by the same insurance. You know, single payer. Meantime, refine the “No Surprises” process.

Project 2025: Adopt free-market methods like price transparency and shared savings.
What it means: Rely on providers to post prices and on patients to choose cheaper options (and share in the savings).
Why it’s bad: Neither works. Most hospitals don’t comply with current price disclosure rules, and the posted lists are so complicated as to be unusable by consumers – far too many procedures and variants, price elements, and health plans. On the patient side, higher prices are seen (incorrectly) as a marker of higher quality, which everyone demands when it comes to medical care. “Skin in the game” strategies don’t control health care costs. Indeed, medical care can not work as a “free market” (Ken Arrow, 1972 Nobel Prize in Economics)
What we need: Proven ways to reduce health care costs – eliminate our massive and massively expensive billing and insurance-related administrative bloat. Negotiate drug and equipment prices. Adopt global budgets.

Medicaid

The proposed changes, despite being couched in bureaucratic buzzwords, have a straightforward and nefarious intent: Reduce health insurance coverage for the poor, by restricting both eligibility and benefits. And, equally worrisome, use Medicaid to suppress access to abortion.

I’m committed to making the phrase “medical insurance for the poor” archaic, by covering everyone well under one system. Meantime, let’s keep this insurance generous.

Project 2025: Reform Medicaid funding with “balanced” match rates, block grants, and caps.
What it means: “Balanced” federal-state funding means that Medicaid would get less federal money (now 65% of the total). “Block grants” and “caps” mean fixed funding, regardless of the size of eligible populations and their medical needs, and slow or no growth over time.
Why it’s bad: This deprives our main health insurance for the poor – already underfunded – of important resources.
What we need: Keep Medicaid robustly funded. Indeed, increase as we did during the COVID pandemic. And end the idea of “health insurance for the poor” – with single payer for all.

Project 2025: Improve Medicaid eligibility standards to protect those in need.
What it means: Cover only the very poorest and sickest, leaving out many who currently qualify and Who, in today’s fragile health insurance environment, meaningfully benefit from Medicaid.
Why it’s bad: The financially and medically *merely* needy – but not in desperate straits – go without insurance and thus with major financial barriers to care.
What we need: Keep Medicaid eligibility so that it reaches all the needy, kindly defined. With single payer, everyone would be covered.

Project 2025: Incentivize personal responsibility: require work & match benefits to individual needs.
What it means: Impose preconditions on program eligibility, and limit coverage to the minimum necessary given financial status and medical need.
Why it’s bad: Work requirements fail – they don’t increase work rates, but do kick people off Medicaid and thus impair access. Limiting coverage is complex, conjectural, and stingy – assuring that tens of millions of beneficiaries will experience significant barriers to care.
What we need: Keep Medicaid eligibility so that it reaches all the needy, reasonably defined. With single payer, everyone would be covered.

Project 2025: Allow Medicaid to contribute to flexible private insurance accounts for families.
What it means: Medicaid money can be used to support health savings accounts instead of public insurance.
Why it’s bad: This represents shifting already inadequate public insurance funds to an approach that benefits private insurers and families with fewer medical needs. This will further weaken the Medicaid mission to protect the poor and sick. It endorses a skin-in-the-game market approach that, as noted elsewhere in this post, does not work.
What we need: Sustain the Medicaid mission to pay for health care for the poor, especially those with greatest medical needs. Once again … with single payer, public funds would pay for health care according to medical need.

Project 2025: Redesign eligibility, financing, and service delivery of long-term care.
What it means: I admit, I’m confused. It elaborates a reasonable sounding goal: “serve the most vulnerable and truly needy and eliminate middle-income to upper-income Medicaid recipients.” Except that, to qualify for Medicaid support for long-term care, there are already strict income and wealth criteria, which work to focus efforts on the needy (although admittedly with gaming by some families).
Why it’s bad: It would be fine to reduce gaming, so that resources are not diverted to families who don’t need them. However, I worry that this serves as a pretext to limit eligibility to the poorest of the poor, impoverishing individuals and spouses.
What we need: Maintain the long-term care benefit. Under single payer, long-term care is an affordable and essential benefit.

Project 2025: No funding for providers that conduct abortions, and severe financial penalties for states that pay for abortions.
What it means: To be clear, this is not refusing to use Medicaid funds to pay for abortion; that’s already in place. This is about penalizing providers and states that in any way support access to abortion.
Why it’s bad: It’s punitive, and contradicts the Right’s supposed deference to states on abortion issues. Thus it further compromises abortion rights, beyond the Supreme Court’s Dobbs reversal of Roe v. Wade.
What we need: Federal funds should not be used to penalize states that permit abortion. Single payer would pay for abortion where legal, and IMO that should be everywhere.

Medicare

Project 2025 proposals focus on increasing the role of private insurers and market solutions. Both, we’ve seen, fail. This approach increases prices, enabling massive financial gains for corporate executives and shareholders.

Project 2025: Increase beneficiary control of care via information about providers & insurance.
What it means: Make it the patient’s responsibility to review and interpret complex information about provider quality and prices.
Why it’s bad: Choice of provider, yes! However, it’s a debunked myth that valuing health care is like valuing cars or phones. Health care is complex and often emotionally fraught. It’s unsuited for this free market approach.
What we need: Let’s stop pretending that a “free market” can fix health insurance. Under single payer, everyone would have free choice of providers, fully paid for, and quality improvement would be a program priority.

Project 2025: Rely on intermediate entities to control costs and improve quality. Make Medicare Advantage the default plan.
What it means: Medicare Advantage private insurance plans and traditional Medicare ACOs & direct contracting entities should operate between beneficiaries and providers.
Why it’s bad: It’s not working, quite the opposite. Medicare Advantage results in >$100 billion in excess spending each year, and huge profits for insurers, while beneficiaries often can’t afford care. ACOs don’t control costs. Neither improves quality.
What we need: Let’s strengthen traditional Medicare by reducing cost-sharing (such as lowering drug prices) and rein in Medicare Advantage abuses. Single payer uses direct funder to provider approaches, with no intermediary profits, shown to work in 32 wealthy nations.

Project 2025: Shift to value-based payments, within traditional Medicare.
What it means: Use VBPs of various types to control costs and raise quality.
Why it’s bad: Value-based payment is a loosely defined idea that financial incentives should foster efficiency in selection and implementation of care. This works for many goods and services, but not for health care – which for patients is driven by pressing need, and for providers is driven by technical expertise and a desire to heal. Health care is not widgets. ACOs, the premier VBP model, failed to achieve goals. VBP is misplaced in health care and distracting.
What we need: Medicare should pay for care, and abandon the failed experiment with VBP. Under single payer, costs are controlled with administrative efficiency, price negotiations, and global budgets; quality is enhanced through research, training, and oversight.

Project 2025: End drug price negotiations; lower the Medicare role for catastrophic drug costs.
What it means: Terminate or subvert the drug price negotiations created by the Inflation Reduction Act. Reduce the program portion (thus raising beneficiary burden) when drug costs accelerate.
Why it’s bad: The IRA provides baby steps toward the much-needed and widely-used (in other nations) drug price negotiations. Pharma can well afford prices that align better with global levels. And it’s especially cruel to abandon beneficiaries when costs are highest.
What we need: Continue to implement and expand drug price negotiations in Medicare. Under single payer, as around the world, that’s how the system assures affordability while allowing solid Pharma profits.