Georgia offered Medicaid with a work requirement. Few have signed up.

“A GOP experiment forcing low-income people to work to qualify for public health insurance benefits is stumbling in Georgia.

The state’s Republican governor, Brian Kemp, expected 31,000 Georgians to sign up in the first year of the program, which started in July. Through four months, only 1,800 people enrolled — and critics blame the paltry expansion on an overly complex program with too many hurdles for people to clear.”

The health care busts that follow mining’s boom-time benefits

“Mining companies offer good jobs with good benefits that can counterintuitively damage health care access. Health systems can grow dependent on those insurance plans to survive, and the benefits are in some cases so good that providers are reluctant to serve others in the community. It’s the consequence of a national health care system that feeds off employer-sponsored health insurance to turn a profit, and, as a result, warps itself to meet the needs of those who have it.
Six months of interviews with more than 90 patients, providers, retired miners, community leaders and health care experts across the U.S., including in three towns characteristic of the mining industry’s past, present and future — Williamson, West Virginia; Elko, Nevada; and White Sulphur Springs, Montana — reveal the breadth of these perils: retired and injured miners, and their families, struggling to get care; communities left with beleaguered or closed health facilities; and pricy hospital bills in towns where mines have driven up median incomes.”

““Doctors want these big reimbursements from the very rich insurance policies that the gold mine provides. They don’t want the pennies they receive from Medicare,” said Jan Brizee, former ombudsman for the Nevada Office for Consumer Health Assistance representing Elko and other rural counties. “So you have somebody who’s retired after 25 or 30 years, and now they have nothing, having to travel out of town to get even primary care, let alone a specialist.”

Not all mining communities experience these problems, and similar issues exist in towns dependent on other industries with good benefits, like manufacturing. But mining communities face unique obstacles compared with other one-company towns — including remoteness and challenging geography — that make it difficult to attract other businesses that would diversify their health insurance landscape.

Miners also tend to be in worse health than their counterparts with other manual labor jobs, with higher rates of poor sleep and heart disease.”

“Medicaid expansion and extra federal funding to support rural health centers and hospitals have helped in some towns. But providers bemoan stingy state Medicaid reimbursement rates that aren’t enough to pay the bills, paltry federal funding to support primary care and hospital designations that don’t meet the needs of all facilities.

For the most part, these solutions have inadequately addressed the systemic failures of employer-based health systems in these communities.”

The US doesn’t have universal health care — but these states (almost) do

“Universal health care remains an unrealized dream for the United States. But in some parts of the country, the dream has drawn closer to a reality in the 13 years since the Affordable Care Act passed.
Overall, the number of uninsured Americans has fallen from 46.5 million in 2010, the year President Barack Obama signed his signature health care law, to about 26 million today. The US health system still has plenty of flaws — beyond the 8 percent of the population who are uninsured, far higher than in peer countries, many of the people who technically have health insurance still find it difficult to cover their share of their medical bills. Nevertheless, more people enjoy some financial protection against health care expenses than in any previous period in US history.

The country is inching toward universal coverage. If everybody who qualified for either the ACA’s financial assistance or its Medicaid expansion were successfully enrolled in the program, we would get closer still: More than half of the uninsured are technically eligible for government health care aid.

Particularly in the last few years, it has been the states, using the tools made available by them by the ACA, that have been chipping away most aggressively at the number of uninsured.

Today, 10 states have an uninsured rate below 5 percent — not quite universal coverage, but getting close. Other states may be hovering around the national average, but that still represents a dramatic improvement from the pre-ACA reality: In New Mexico, for instance, 23 percent of its population was uninsured in 2010; now just 8 percent is.

Their success indicates that, even without another major federal health care reform effort, it is possible to reduce the number of uninsured in the United States. If states are more aggressive about using all of the tools available to them under the ACA, the country could continue to bring down the number of uninsured people within its borders.

The law gave states discretion to build upon its basic structure. Many received approval from the federal government to create programs that lower premiums; some also offer state subsidies in addition to the federal assistance to reduce the cost of coverage, including for people who are not eligible for federal aid, such as undocumented immigrants. A few states are even offering new state-run health plans that will compete with private offerings.”

Patients don’t know how to navigate the US health system — and it’s costing them

“Research has shown that people will skip necessary care if they have even a small cost to pay, and recent surveys find one in three Americans say they have postponed medical treatment in the last year due to the cost.”

“The Perry Undem survey, which polled nearly 2,700 Americans on behalf of the American Cancer Society’s Cancer Action Network, the Leukemia and Lymphoma Society, and RIP Medical Debt, also detected widespread struggles to afford health care. About 7 in 10 people say they have received a medical bill that they could not afford, it found, and more than 60 percent of Americans said they had made some kind of sacrifice — delaying care, skipping appointments, changing the food they buy at the grocery store, etc. — in order to afford health care in the past two years.”

“About 40 percent of people said they were always or frequently unsure how much their medical services would cost after they received care, according to the Perry Undem survey; another 30 percent said they were uncertain about the costs at least some of the time. Nearly two-thirds of US patients said they were at least sometimes unsure how much their insurance plan would cover after being treated.”

“About 6 in 10 Americans said they had experienced a problem using their health insurance in the past year, according to KFF.”

Nearly 2 million kids have been kicked off Medicaid this year

“In the six months since states began double-checking the eligibility of people enrolled in their Medicaid programs for the first time in three years, more than 8.5 million Americans have lost their Medicaid benefits.
Based on enrollment numbers at the start of the year, that means roughly 1 in 10 people covered by Medicaid have lost their health insurance in a matter of months. After the US saw its uninsured rate hit historic lows during the pandemic, millions of the most vulnerable Americans are now falling off the rolls — with no assurance they will be able to find another form of coverage.

Worse, many of those losing coverage are losing it because of administrative hiccups and would otherwise be eligible — a problem that is disproportionately impacting children.

We won’t know until next year’s national insurance surveys how many people simply ended up uninsured and how many people successfully enrolled in another form of health coverage even as they lost their Medicaid benefits. But it is safe to expect that millions more Americans are now uninsured than were at the beginning of the year.

The health effects of this massive loss in health insurance will take years to be realized. But we know that having Medicaid means people are more likely to see a doctor and keep up with managing chronic conditions. The program helps people live longer. So losing coverage will make it even more difficult for a population that already struggles with its health to stay well.

Here’s why this is happening: During the pandemic, Congress approved an emergency provision that prevented almost anyone from losing their Medicaid coverage. Even if you had a change in income or life circumstances that in normal times would have led to you leaving the program, you were allowed to stay as long as that emergency policy was in place. But that provision expired earlier this year, part of the government standing down from its pandemic footing, and states were tasked with double-checking the eligibility of every person who was on their Medicaid rolls — a process referred to as unwinding. Starting in April, they could remove people who they found were no longer eligible.”

Fixing open enrollment starts with staying mad about it

“Almost four in 10 Americans — 38 percent — said that in 2022 they had put off medical care because of the cost, per Gallup. That is the highest number ever recorded since the polling firm started asking the question in 2001. Another survey, from KFF over the summer, found 28 percent had difficulty affording prescription drugs.
The truth is that insurance alone isn’t always enough to help people afford health care. The Commonwealth Fund concluded that 43 percent of Americans had been “inadequately insured” in 2022. That meant either they had been uninsured, had a gap in coverage during the year, or the insurance they had would not be adequate if they had an expensive medical emergency or diagnosis — for example, if their plan’s out-of-pocket costs could exceed 10 percent of their household income.

More than 40 percent of people said they had skipped care due to its cost, or they had trouble paying off medical bills, medical debt, or both.

It does not have to be this way. There is not one specific prescription for fixing health care. Countries have found various ways to make health insurance more affordable, standardized, and universal”

The subtle privatization of Medicare

“If you’re signing up for Medicare benefits this open enrollment, odds are you aren’t actually enrolling in the traditional government program that people may envision. More than half of Medicare beneficiaries are now choosing an alternative version of the program administered by private companies.
Medicare, the paragon of America’s welfare state, is undergoing a subtle but fundamental transformation from government program to public benefit provided by private companies, a shift with major implications for both patients and taxpayers. This alternative version of Medicare, known as Medicare Advantage, now covers more than half of the program’s 60 million enrollees, or about 31 million Americans — nearly double its share 10 years ago.”

“Medicare Advantage allows private insurers to offer their own plans that provide Medicare benefits, as well as some additional perks not available in the original program. The secret to the program’s success is simplicity. Traditional Medicare is a fragmented program: Part A covers hospital care, and Part B covers outpatient services. Patients must enroll in a separate Part D plan for prescription drug coverage that is administered by private insurers. Most people also purchase supplemental coverage, extra insurance that helps reduce their out-of-pocket costs.

Medicare Advantage, also known as Part C, combines those benefits into one insurance plan that also includes an annual limit on out-of-pocket costs, something that does not technically exist in regular Medicare.

But the benefits to patients seem to come at a cost to taxpayers. Though the health insurance industry disputes these findings, MedPAC, the independent committee tasked with overseeing Medicare on Congress’s behalf, found Medicare Advantage plans cost the federal government more money per patient than the original program would have if those same people had stuck with the traditional benefits.

Private companies are also making healthy margins on their Medicare business.”

“Patients have clearly found something to like in what Medicare Advantage offers. The program was established in 1997 to give people a streamlined alternative, a private option less overt than more recent GOP voucher proposals.

But scholarly research and media investigations have revealed notable downsides in turning over a program that covers America’s seniors, the people who need and use the most health care, to private companies. Medicare Advantage enrollees are more likely to report trouble affording health care than people on traditional Medicare. Some of the behavior by Medicare Advantage plans, such as using AI to decide when to stop covering services for their enrollees, may be becoming more common in the private sector but is still unheard of for public programs.

The trade-off the United States seems to be making is accepting more administrative bloat and more stringent provision of benefits in exchange for a more navigable Medicare plan. The trade-off is one other countries have made as they designed universal health care programs. (A similar trend is underway in Medicaid.)

But as concern grows about Medicare facing a potential financial cliff, and evidence mounts about the costs of Medicare Advantage, the risks of the trade-off are becoming clearer. Medicare is no longer what it used to be: Once the epitome of government-run health insurance, its benefits are on the verge of being primarily funneled through private companies. Any attempts to change the program will have to wrestle with that reality.”

“Why the movement? In a 2021 analysis published in Health Affairs, Ken Terry and David Muhlestein observed that “we’re witnessing the rapid privatization of Medicare” and offered an explanation: Medicare Advantage plans “offer beneficiaries a better deal than traditional Medicare.”

The premiums people pay for a Medicare Advantage plan can be significantly lower than the combined cost of supplemental coverage and a Part D plan — less than $50 compared to more than $200 on average, per Terry and Muhlestein — with the added benefit of having only a single insurance card. According to a 2022 Commonwealth Fund survey, the additional benefits offered by Medicare Advantage plans (such as dental or vision) and the limits on out-of-pocket costs were the most common reasons seniors gave for choosing the alternative over the original program.

In general, patients with traditional Medicare and people with Medicare Advantage say they have similar satisfaction with their benefits. On some metrics, the latter group excels; people with a Medicare Advantage plan are more likely to have a regular doctor and to say they have received preventive health care services. With a few exceptions for particular medicines, Medicare Advantage customers report fewer problems accessing their prescription drugs, too.

But people enrolled in Medicare Advantage also experience a unique set of problems compared to people who choose the original program.”

“A higher percentage of Medicare Advantage enrollees report having problems affording care (about 19 percent, per a 2021 KFF analysis) than those on traditional Medicare (15 percent), though people on the original program without supplemental coverage had the most problems with affordability (30 percent). (Most people on Medicare do purchase this coverage.) Black Americans and people with lower incomes were more likely to report having trouble paying for health care while enrolled in Medicare Advantage.

Other findings appear worrisome, too. Medicare Advantage patients are less likely to receive medical care at the highest-rated facilities for their particular needs, compared to people with traditional Medicare, a reflection of more restrictive provider networks. Families also reported more satisfaction with end-of-life care when using traditional Medicare.

Specific business practices by Medicare Advantage plans, and their consequences for patients, have also been called into question by investigative reporting and government inquiries over the past few years, practices that seem to run counter to Medicare’s function as an entitlement program for Americans over 65 and those with long-term disabilities.

Earlier this year, STAT reported on the increasing use of AI algorithms by these plans to determine when to cut off benefits for a customer. The lead example of their reporting was an 85-year-old woman with a broken left shoulder, whose insurer followed an algorithm that said she should be ready to leave a nursing facility and return home within 17 days.

On the 17th day of her stay, the insurer said it would no longer cover the bills for her stay, even though her doctors and nurses observed that the woman was still in extreme pain and incapable of doing basic activities, such as dressing herself or going to the bathroom. It took more than a year, and a federal judge’s order, for the patient to receive payments for the three additional weeks she needed to stay in the nursing facility. Doctors shared other stories of patients who saw benefits withdrawn at the end of their life, leaving their families to fight over the leftover bills for years after their loved one had died.

A report from federal investigators published in April 2022 found that tens of thousands of Medicare Advantage customers were denied coverage for services they should have been entitled to. A significant number of prior authorization denials (13 percent) and payment denials (19 percent) reviewed by the investigators were for services that should have been covered by the program but were not.

“Denied requests that meet Medicare coverage rules may prevent or delay beneficiaries from receiving medically necessary care and can burden providers,” they wrote. “Even when denials are reversed, avoidable delays and extra steps create friction in the program.”

In addition, as the New York Times reported last October, most of the largest Medicare Advantage insurers have been the subject of federal audits that found they improperly billed the program and of litigation that accused them of fraud. Taken together, the plans overbilled Medicare by between $12 billion and $25 billion in 2020, depending on the estimate.

Though Medicare Advantage was first established as a tool for reining in spending, these private plans instead seem to be perpetuating the program’s solvency crisis.

According to MedPac, since 2004, Medicare has always paid more to Medicare Advantage insurers for the cost of covering their customers than the program would have spent if the same beneficiaries had instead been enrolled in traditional Medicare. Some years, the private plans were receiving a nearly 20 percent markup compared to the original benefit structure.”

“The growth of Medicare Advantage is contributing to the financial crunch. Those plans receive funding based on the type of service provided to their customer, which means money for hospital care comes from Part A. Annual Part A payments to Medicare Advantage plans are expected to increase from about $176 billion in 2022 to $336 billion by 2030.

With revived concerns over Medicare’s solvency and evidence of excess spending in Medicare Advantage, policymakers are starting to look at making changes to the program. But that won’t be easy.”

“Health insurers are going to fiercely defend their Medicare Advantage business against any proposed cuts”

“It is difficult, at this point, to imagine the Medicare program without Medicare Advantage. The question is whether policymakers can make it more cost-effective and crack down on insurer behavior that runs counter to the program’s objectives. Recent events suggest that if they try, they will have a fight on their hands.”