“Sometimes you don’t need a smoking gun, you just need to look at who keeps getting burned. Then examine who keeps breathing just fine on the other side of the fire.”
Too many folks continue to demand “smoking guns” before they’ll be convinced they’re being deliberately kicked in the guts. But if we look at who is winning, who is losing and who has the power, it’s not difficult to draw conclusions.
The medical-industrial complex, emerging during the Reagan administration, shifted the model of healthcare away from the voluntary, non-profit paradigm to a deregulated for-profit structure. Consequently, profit and shareholder returns trumped administration of care delivery and incenting quality improvement.
Silos of profit centers myopically manage their delivery missions, focused on maximizing profit. Limiting and denying care, procedures and medication availability squeeze out profits from money not spent from the medical loss ratio, a contracted budget line item allocating a projected expense account dedicated to paying for healthcare claims. Since this annual contracted sum is paid to the silo profit center ( pharmacy benefit managers, capitated service providers, behavioral health and other specialty managed care entities), each silo's priority is limiting utilization to extract profits. Each silo operating independently has no investment in coordination of care, prevention, or improving health outcomes.
The ACA attempts to create the right incentives, promote better outcomes and police price gouging, undermining the fundamentals of the medical-industrial complex, where profit is king.
We can absolutely develop a much better healthcare delivery system. There are many moving parts and complicated systemic interfaces. However, smart professionals, given the proper tools and latitude to incubate delivery models with proper funding, could design a system that is effective and responsible. The medical-industrial complex model simply throws our healthcare to the wolves.
Our health care system is so broken, yet it’s making some people very very wealthy.
I can’t stand the Medicare Advantage ads. They just sound too good to be true. I want to yell, “It’s a scam to make money for the insurance companies!”
If something good grows out of the wreckage, maybe it can be a for-real single-payer system.
One tenet of the original ACA was the individual mandate which penalized financially anybody who did not buy a medical care policy. It turned out that the penalty wasn’t enough to get the young healthy people to buy a policy. Australia faced the same issue with their system- their solution was
simply to raise the penalty. Our solution was to delete the individual mandate which resulted in the healthy young people abandoning the ACA which depended on the premiums of those healthy young people.
I certainly agree with your evaluation of the GOP's abysmal inability to come up with a health care plan and with the proliferation it tries to promote of junk alternatives to the ACA. I do question, however, some of the bromides? cliches? about Medicare Advantage.
1. I've had Medicare Advantage for 16 years, and before that coverage with the same insurance carrier through my employment for 15 years prior to that. It is the largest Medicare Advantage Insurer in the country. During that time I have had a handful of denials, all but one of which turned out to be errors by my medical provider either in coding or in the wording of their requests for pre-approval. The one was from the dental plan adjunct to my main coverage; it was completely wrong, I refused to pay the dentist, and HE got the "ruling" changed. I changed dental insurers. (the denial was for filling a cavity in a tooth that was opposed to an extracted tooth as if the fact that extractions end up with teeth shifting around means teeth can't get cavities)
So my personal experience--maybe I've been exceptionally lucky--is that the company has not made anything at all from denying my claims. I have 6 different serious health issues and see specialists for them regularly. So the company is not making money off me because I am healthy. In fact, my program is 0 premium and so all the company gets for my health is Medicare Part B.
I was NOT attracted to MA by exercise programs or similar goodies, though there are a few useful features like consulting nurses and some forms of home health service.
2. I asked an insurance agent (not one for my insurer) how Medicare Advantage COULD make money given my own paltry contributions. The answer was simple. An HMO allows only certain doctors on their approved list, and to GET on the approved list the doctor has to accept a contractual price for various codes that is LESS than what Medicare would pay for the same code. In return the provider gets a large pool of probable patients. The Advantage insurer gets what normal Medicare pays for the code. The delta is where the company makes its money.
But WAIT? Isn't that "cheating the government?" Uh, the government pays exactly what it would for the procedure were I on normal Medicare. From that delta comes the PATIENT'S ability to pay zero premium.
This is why Medicare Advantage uses the HMO model.
3. Under the statute allowing Medicare Advantage, the company must provide the SAME coverage, in terms of things covered, as regular Medicare. It can put certain restrictions on what it takes to get that coverage--mainly required referrals and pre-approvals--that regular Medicare recipients don't necessarily have to face. I have always been covered by an HMO, since 1968, so those restrictions don't bother me at all. I haven't seen, in all the fuss about denials, a breakout of how many denials happen because the patient doesn't understand or follow the rules.
4. These plans are definitely not for everyone. They work best in large metropolitan areas where a whole lot of doctors participate in the HMO. Smaller areas may not have the number of available providers and finding one you like and trust may be much harder. It really is up to the consumer to research this before signing up. If you want "your own doctor" and s/he isn't in the plan, don't go for the plan.
My plan has never had a different treatment of pre-existing conditions. Several of my conditions existed before I hit Medicare age, and are covered still. One problem with switching back from Medicare Advantage to regular Medicare is that the Medicare supplemental plans CAN deny you for pre-existing conditions, unlike the ACA.
5. I do challenge the statement that "companies that stand to profit most from the broader Trump-era health agenda aren’t the ACA insurers at all. They’re the giants of Medicare Advantage..." I just checked: Of the 5 biggest Medicare Advantage plans, all but one (Humana) participate in the ACA marketplace (another is leaving for 2026 because of the uncertainties of the ACA in its current state).
6. Oversight. That IS a problem, making sure any MA company indeed abides by the statute and doesn't abuse with wrongful denials. The pattern of oversight in the US of insurers (ANY insurer) is via the state Insurance Commissioners. Some of those can be very lax; where I live, we have a strong IC and that may be why I've been so lucky.
But Medicare and Medicare Advantage are federal programs and I don't see why stricter federal oversight of abuses can't be part of the package. Not in this administration, of course, but I have to believe we will get back from the gutting of the administrative protections of federal law. Trust that things will get better is really the only thing that keeps most of us going--that and working TOWARDS making things better
7. It is indeed quite probable that if the ACA vanishes we will be back in a world of junk plans and denials for pre-existing conditions and lack of consistent regulation by some ICs who are industry bought and paid for. All I am trying to say is that basing an argument on the idea that Medicare Advantage is some sort of boogie man we are all heading towards. In fact, Medicare Advantage may be one of the few models that still involves possible federal regulation to combat the shysters.
Big is not necessarily evil. In fact, my insurer is gung ho for preventative care. I am rewarded with low copays if I keep up check-ups by my various specialists. Ironically, if we do end up with universal health care, and eliminate health insurance companies entirely, there is going to be a huge need for claims professionals. No one really wants the government to pay for nose jobs or tummy tucks done solely for beautification. Guess what industry they will be drawn from? Same folks, some good, some bad as you are dealing with now. Better regulation of the bad--but that is possible with insurance companies benefitting from federal funds who can be regulated because of those funds way better than the patchwork of state ICs now often failing to do their jobs. Just keep Mehemet Oz from being involved. He's definitely an apple-spoiling addition to the barrel.
It is a simple proposition: Is it a for-profit healthcare an industry or an indispensable public service. Sadly, for too many, it is the former. The ACA for its good, to increase access, did so acknowledging the obvious: insurance companies and healthcare organizations. Both manage risk. For insurers, the actuarial risk pools. For the hospitals and clinics, optimization of services (a balance of sufficient care and beds). And to both, the irresistible draw of the $1T / year outlay from CMS as Ms Geddry referenced.
Those of us on the Left lean toward Medicare for All. Yes, it is social medicine and not wholly great. FICA taxes most certainly would increase. Healthcare would likely be rationed to assure the most needed occurs, the less delayed, and the elective mostly gone. But in strong argument, essential care would occur immediately, and the less after a waiting period. But in the end, more efficient. More importantly, universal in its scope. I note, in Europe, individuals may purchase insurance for healthcare beyond essential.
Unfortunately for us, healthcare is a for-profit industry. Rationing in its case is economic denial for people who cannot afford the premiums. A sop, ER healthcare. Risk managed by actuarial tables. The ACA attempt to achieve some equity now appears thwarted. It would seem Oz’s principal goal, to shift the $1T more directly into the industry while simultaneously reducing the frictions of high risk pools. In short, the GOP focus is more on campaign contributions and not public health. They aren’t looking for government solution, they are looking for government disinvestment. From polls, it would appear the majority disagree with the GOP’s disinvestment.
“Sometimes you don’t need a smoking gun, you just need to look at who keeps getting burned. Then examine who keeps breathing just fine on the other side of the fire.”
Too many folks continue to demand “smoking guns” before they’ll be convinced they’re being deliberately kicked in the guts. But if we look at who is winning, who is losing and who has the power, it’s not difficult to draw conclusions.
The medical-industrial complex, emerging during the Reagan administration, shifted the model of healthcare away from the voluntary, non-profit paradigm to a deregulated for-profit structure. Consequently, profit and shareholder returns trumped administration of care delivery and incenting quality improvement.
Silos of profit centers myopically manage their delivery missions, focused on maximizing profit. Limiting and denying care, procedures and medication availability squeeze out profits from money not spent from the medical loss ratio, a contracted budget line item allocating a projected expense account dedicated to paying for healthcare claims. Since this annual contracted sum is paid to the silo profit center ( pharmacy benefit managers, capitated service providers, behavioral health and other specialty managed care entities), each silo's priority is limiting utilization to extract profits. Each silo operating independently has no investment in coordination of care, prevention, or improving health outcomes.
The ACA attempts to create the right incentives, promote better outcomes and police price gouging, undermining the fundamentals of the medical-industrial complex, where profit is king.
We can absolutely develop a much better healthcare delivery system. There are many moving parts and complicated systemic interfaces. However, smart professionals, given the proper tools and latitude to incubate delivery models with proper funding, could design a system that is effective and responsible. The medical-industrial complex model simply throws our healthcare to the wolves.
Our health care system is so broken, yet it’s making some people very very wealthy.
I can’t stand the Medicare Advantage ads. They just sound too good to be true. I want to yell, “It’s a scam to make money for the insurance companies!”
If something good grows out of the wreckage, maybe it can be a for-real single-payer system.
One tenet of the original ACA was the individual mandate which penalized financially anybody who did not buy a medical care policy. It turned out that the penalty wasn’t enough to get the young healthy people to buy a policy. Australia faced the same issue with their system- their solution was
simply to raise the penalty. Our solution was to delete the individual mandate which resulted in the healthy young people abandoning the ACA which depended on the premiums of those healthy young people.
I certainly agree with your evaluation of the GOP's abysmal inability to come up with a health care plan and with the proliferation it tries to promote of junk alternatives to the ACA. I do question, however, some of the bromides? cliches? about Medicare Advantage.
1. I've had Medicare Advantage for 16 years, and before that coverage with the same insurance carrier through my employment for 15 years prior to that. It is the largest Medicare Advantage Insurer in the country. During that time I have had a handful of denials, all but one of which turned out to be errors by my medical provider either in coding or in the wording of their requests for pre-approval. The one was from the dental plan adjunct to my main coverage; it was completely wrong, I refused to pay the dentist, and HE got the "ruling" changed. I changed dental insurers. (the denial was for filling a cavity in a tooth that was opposed to an extracted tooth as if the fact that extractions end up with teeth shifting around means teeth can't get cavities)
So my personal experience--maybe I've been exceptionally lucky--is that the company has not made anything at all from denying my claims. I have 6 different serious health issues and see specialists for them regularly. So the company is not making money off me because I am healthy. In fact, my program is 0 premium and so all the company gets for my health is Medicare Part B.
I was NOT attracted to MA by exercise programs or similar goodies, though there are a few useful features like consulting nurses and some forms of home health service.
2. I asked an insurance agent (not one for my insurer) how Medicare Advantage COULD make money given my own paltry contributions. The answer was simple. An HMO allows only certain doctors on their approved list, and to GET on the approved list the doctor has to accept a contractual price for various codes that is LESS than what Medicare would pay for the same code. In return the provider gets a large pool of probable patients. The Advantage insurer gets what normal Medicare pays for the code. The delta is where the company makes its money.
But WAIT? Isn't that "cheating the government?" Uh, the government pays exactly what it would for the procedure were I on normal Medicare. From that delta comes the PATIENT'S ability to pay zero premium.
This is why Medicare Advantage uses the HMO model.
3. Under the statute allowing Medicare Advantage, the company must provide the SAME coverage, in terms of things covered, as regular Medicare. It can put certain restrictions on what it takes to get that coverage--mainly required referrals and pre-approvals--that regular Medicare recipients don't necessarily have to face. I have always been covered by an HMO, since 1968, so those restrictions don't bother me at all. I haven't seen, in all the fuss about denials, a breakout of how many denials happen because the patient doesn't understand or follow the rules.
4. These plans are definitely not for everyone. They work best in large metropolitan areas where a whole lot of doctors participate in the HMO. Smaller areas may not have the number of available providers and finding one you like and trust may be much harder. It really is up to the consumer to research this before signing up. If you want "your own doctor" and s/he isn't in the plan, don't go for the plan.
My plan has never had a different treatment of pre-existing conditions. Several of my conditions existed before I hit Medicare age, and are covered still. One problem with switching back from Medicare Advantage to regular Medicare is that the Medicare supplemental plans CAN deny you for pre-existing conditions, unlike the ACA.
5. I do challenge the statement that "companies that stand to profit most from the broader Trump-era health agenda aren’t the ACA insurers at all. They’re the giants of Medicare Advantage..." I just checked: Of the 5 biggest Medicare Advantage plans, all but one (Humana) participate in the ACA marketplace (another is leaving for 2026 because of the uncertainties of the ACA in its current state).
6. Oversight. That IS a problem, making sure any MA company indeed abides by the statute and doesn't abuse with wrongful denials. The pattern of oversight in the US of insurers (ANY insurer) is via the state Insurance Commissioners. Some of those can be very lax; where I live, we have a strong IC and that may be why I've been so lucky.
But Medicare and Medicare Advantage are federal programs and I don't see why stricter federal oversight of abuses can't be part of the package. Not in this administration, of course, but I have to believe we will get back from the gutting of the administrative protections of federal law. Trust that things will get better is really the only thing that keeps most of us going--that and working TOWARDS making things better
7. It is indeed quite probable that if the ACA vanishes we will be back in a world of junk plans and denials for pre-existing conditions and lack of consistent regulation by some ICs who are industry bought and paid for. All I am trying to say is that basing an argument on the idea that Medicare Advantage is some sort of boogie man we are all heading towards. In fact, Medicare Advantage may be one of the few models that still involves possible federal regulation to combat the shysters.
Big is not necessarily evil. In fact, my insurer is gung ho for preventative care. I am rewarded with low copays if I keep up check-ups by my various specialists. Ironically, if we do end up with universal health care, and eliminate health insurance companies entirely, there is going to be a huge need for claims professionals. No one really wants the government to pay for nose jobs or tummy tucks done solely for beautification. Guess what industry they will be drawn from? Same folks, some good, some bad as you are dealing with now. Better regulation of the bad--but that is possible with insurance companies benefitting from federal funds who can be regulated because of those funds way better than the patchwork of state ICs now often failing to do their jobs. Just keep Mehemet Oz from being involved. He's definitely an apple-spoiling addition to the barrel.
It's late, please excuse typos.
It’s not left or right but up and down. Again
It is a simple proposition: Is it a for-profit healthcare an industry or an indispensable public service. Sadly, for too many, it is the former. The ACA for its good, to increase access, did so acknowledging the obvious: insurance companies and healthcare organizations. Both manage risk. For insurers, the actuarial risk pools. For the hospitals and clinics, optimization of services (a balance of sufficient care and beds). And to both, the irresistible draw of the $1T / year outlay from CMS as Ms Geddry referenced.
Those of us on the Left lean toward Medicare for All. Yes, it is social medicine and not wholly great. FICA taxes most certainly would increase. Healthcare would likely be rationed to assure the most needed occurs, the less delayed, and the elective mostly gone. But in strong argument, essential care would occur immediately, and the less after a waiting period. But in the end, more efficient. More importantly, universal in its scope. I note, in Europe, individuals may purchase insurance for healthcare beyond essential.
Unfortunately for us, healthcare is a for-profit industry. Rationing in its case is economic denial for people who cannot afford the premiums. A sop, ER healthcare. Risk managed by actuarial tables. The ACA attempt to achieve some equity now appears thwarted. It would seem Oz’s principal goal, to shift the $1T more directly into the industry while simultaneously reducing the frictions of high risk pools. In short, the GOP focus is more on campaign contributions and not public health. They aren’t looking for government solution, they are looking for government disinvestment. From polls, it would appear the majority disagree with the GOP’s disinvestment.