Why Medicare for All?

If you ever doubted that the profit motive and government ignorance are not places for healthcare, read these articles:

I Set Out to Create a Simple Map for How to Appeal Your Insurance Denial. Instead, I Found a Mind-Boggling Labyrinth.  By Cheryl Clark for ProPublica
Aug. 31, 5 a.m. EDT

Have you ever had a health care claim denied by your insurer? Ever tried to appeal it? Did you wind up confused, frustrated, exhausted, defeated?

I’ve been a healthcare reporter for more than 40 years. And when I tried to figure out how to appeal insurance denials, I wound up the same way. And I didn’t even try to file an actual appeal.

ProPublica came to me earlier this year with what might have seemed like a simple proposition. They wanted me to create an interactive appeals guide to help readers navigate their insurers’ maze. (ProPublica and The Capitol Forum reporters have been investigating how insurers deny health care payments.) 

Over the next several weeks, I spoke with more than 50 insurance experts, patients, lawyers, physicians, and consumer advocates.

Nearly everyone said the same thing: Great idea. But almost impossible to do.

The insurance industry and its regulators have made it so complicated to file an appeal that only a tiny percentage of patients ever do.

For example, less than two-tenths of 1% of patients in Obamacare plans bothered to appeal claims denied in 2021.

The central problem: There are many kinds of insurance in the U.S., and they have different processes for appealing a denial.

And no lawmakers or regulators in state and federal governments have forced all insurers to follow one simple standard.

So that’s problem #1. Too many different kinds of healthcare insurance plans are available.

Why? The profit motive and government ignorance. 

Private insurers are focused on two issues: Offering an attractive insurance product to the public and making that product as profitable as possible.

With the profit motive in mind, private companies offer different plans for young and old, male and female, various health degrees, job types, geography, and many other factors.

First, people have to know precisely what kind of insurance they have. You may think that UnitedHealthcare is your insurer because that’s the name on your insurance card, but that card doesn’t tell you what kind of plan you have.

Your real insurer may be your employer. Some 65% of workers who get their coverage through their employers are in what’s known as “self-funded plans,” according to KFF (formerly Kaiser Family Foundation).

That means the employer pays for medical costs, though it may hire an insurance company like UnitedHealthcare to administer claims.

Because no employer has the unlimited funds that the federal government has, the cost of employer-funded medical insurance must come from somewhere within the company. It comes from employee salaries.

If your employer provides healthcare insurance, the cost is figured into the salary he is willing to pay you. Thus, your salary could be higher if the federal government paid the insurance bill.

The other primary type of insurance companies provide for their workers is a “fully insured plan.”

The employer hires an insurer to take all the risk and pay the claims. With that kind of plan, the name on your card really is your insurer. Why does this difference matter?

Because the route you follow to challenge an insurance denial can differ based on whether it’s a fully insured plan or a self-funded one.

A government-funded Medicare for All would not need to consider these differences. You would have one source for all information and appeals — and probably less reason to appeal in the first place.

And we can’t forget about Medicaid and the Children’s Health Insurance Programs, which cover over a quarter of the U.S. population.

The federal government sets minimum standards that each state Medicaid program has to follow. Still, states can make things more complicated by requiring different appeal pathways for different types of health care.

So, the process can differ depending on the type of care that was denied, which can vary from state to state.

Having infinite money and no profit motive, a government-sponsored Medicare for All plan could provide total, no-deductible coverage for every situation.

A state-by-state guide to Medicaid: Do I qualify?

President Obama’s health care law moved to standardize Medicaid requirements, expressly so any American making up to 133% of the poverty line could qualify.

But that provision was challenged and overturned by the Supreme Court. States could expand Medicaid, but they no longer had to.

Thirty-nine states (plus Washington, D.C.) did; 11 have not.

And eligibility across states varies since the Trump administration announced it would allow states to impose work requirements for low-income and needy Americans receiving Medicaid.

In other words, figuring out whether you qualify for Medicaid is even more challenging than before. Enter our state-by-state guide to Medicaid, which we’ll update as changes go into effect.

A comprehensive, no-deductible Medicare for every man, woman, and child in America would solve all the above problems.

CMS Proposes Rule to Limit Medicare Advantage Plan Sales Commissions
— No more golf parties or free trips to brokers who “steer” beneficiaries to higher-paying plans
by Cheryl Clark, Contributing Writer, MedPage Today November 7, 2023

To stop Medicare Advantage (MA) and Part D plan marketing agents from steering beneficiaries into plans that pay the agents the highest commissions — rather than the plans that best suit the patients’ needs — the Centers for Medicare & Medicaid Services (CMS) proposed a rule Monday that would limit the amount they’d receive on sales to $632 for the 2025 plan year.

Currently, agents can receive far more than the current national commission cap of $601, even as high as $1,300 on one sale for 1 year’s enrollment, because of “add-on” or “incentive fees,” according to a recent Senate committee hearing testimony. CMS called the practice “anti-competitive steering” since larger plans are usually paying the most, putting smaller, potentially better plans at a disadvantage.

The agency said it has seen web-based ads that offer agents and brokers “bonuses and perks (such as golf parties, trips, and extra cash) in exchange for enrollments.”

The payments are implemented in a way that allows the plan sponsor “to credibly account for these anti-competitive payments as ‘administrative’ rather than ‘compensation,’ and these payments are therefore not limited by the regulatory limits on compensation.”

Another provision in the proposed rule would require MA plans to demonstrate in their bids to Medicare that unique supplemental benefits for the chronically ill have a reasonable expectation of improving the health or overall function of enrollees with chronic illness.

Provisions would also require federal quality improvement organizations — instead of representatives of the MA plans — to review a fast-track appeal when the plan has decided to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility, or a home health agency.

Such fast-track review is now available to traditional Medicare beneficiaries in fee-for-service but not to those in MA plans.

The whole rationale for Medicare Advantage Plans is based on two problems with Medicare:

1. Medicare pays only 80% for most things, requiring people to purchase “Medicare Supplement” insurance to cover the balance.
2. Medicare doesn’t cover everything. Strangely, it omits dental, weight loss, long-term care, hearing aids, most vision care, hearing aids, cosmetic surgery, some foot care, adult diapers, and deductibles.

Why are these not covered? It’s the same old debt lie — the false belief that somehow the Monetarily Sovereign federal government can run short of its own sovereign currency, the U.S. dollar — so the public (which has limited funds) should pay.

The mere existence of the alternative to the original Medicare, Medicare Advantage, demonstrates the needless lies that form the basis for federal spending, or lack thereof.

SUMMARY

Healthcare is one of the government’s most essential functions, yet the U.S. government falls far short in its meager efforts.

Original Medicare has many shortcomings, all of which are based on the false beliefs that our Monetarily Sovereign federal government has limited funds and is supported by tax dollars.

Every shortcoming of Medicare could be solved by a comprehensive, no-deductible, federally funded Medicare for every man, woman, and child in America.

And no:

1. It isn’t Socialism (Government ownership) and
2. It won’t cause inflation. (Caused by shortages; cured by federal spending).

Rodger Malcolm Mitchell
Monetary Sovereignty

Twitter: @rodgermitchell Search #monetarysovereignty
Facebook: Rodger Malcolm Mitchell

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The Sole Purpose of Government Is to Improve and Protect the Lives of the People.

MONETARY SOVEREIGNTY