Return of the Socreds

Presto Manning is contemplating a run for the leadership of the Party of Calgary. Somethings never change. Preston Manning Expresses Interest In Replacing Klein

That would mean 35 years of Socred power that ended with his father, Ernest, being replaced with a lame duck Premier, then 33 years of PC power starting with Peter Lougheed and ending with a lame duck Premier, and then the possibility of that strange beast the Reformed PC Socreds under Presto.....noooooooo.

Preston Manning, who was once the second-most-powerful leader in Canada as leader of the opposition, is apparently now considering his chances of becoming the second-most-powerful leader in Canada as premier of Alberta.

King Ralph is dead
The Alberta Tories' regicide of Ralph Klein was big news for 12 hours. Then Preston Manning trumped it, telling reporters he was considering running for Klein's job.

Daddy Ernest Manning gave up party power to Peter Lougheed, thus assuring a Liberal Conservative Socred Alliance that was Seventies PC's. That alliance was shattered as neo-cons took over under Klein, the fiscal right was far less powerful than the social conservatives. The social conservatives align behind Oberg, the Reform types around Morton, and the liberal wing under Dinning. Alberta Tories in disarray

Dining did the dirty deed of balancing the budget on the backs of the working class, with wage and benefit cuts to the public sector. Then with victory in his back pocket he left the government.

The neo-cons in the party then went on to shape the Ralph Revolution, using the the debt and deficit hysteria of the ninties to impose their Republican Lite vision on Alberta, while promoting it for the rest of Canada with Prestos Reform Party.

Government that governs least is best — or not

When Mr. Klein became premier, the province had a $3.4-billion deficit and a $23-billion debt. He argued these burdens arose, in part, from governments having involved themselves too much in the economy. There were bad investments. The government taxed too much. Government regulations were too onerous. The free market, he asserted, would be encouraged if the government got out of the way.

This contrasted with the approach of Peter Lougheed, who led the Conservatives to power in 1971. Mr. Lougheed was no socialist, but he did believe the government should try to direct, cajole and even force the market in directions he believed Alberta needed. Only that way, he reasoned, could Alberta's economy be diversified and energy revenues used not just for today's needs, but for the future.

Mr. Lougheed's dirigiste preferences evaporated under Mr. Klein, but now some Albertans want that kind of guiding hand back, at least in a modified form. In a free-enterprise province, the critics are now demanding a “plan” for using the revenues that would be more than driving up spending on ongoing programs.

Presto would be an interesting add to the mix but his chances of winning are less than none. Unless he has something up his sleeve, oh like say Medicare Reform. If anyone could enunciate and promote the Third Way in Medicare it would be Presto.

“Where I think we're headed is a system of universal care, where everybody is covered ... with two tracks for delivery, and two tracks for payment. It's not a question of private versus public, but what mix of the two is appropriate.”

Mr. Manning left what he likes to call "active partisan politics" in 2002 to become more involved in the public-policy debate. He quickly got on board with the Fraser Institute and the Canada West Foundation, and he set up the Manning Centre for Building Democracy.

He and Mike Harris authored the Fraser Institute Report on exactly the musings that King Ralph has been tossing about for the past decade. And perhaps that would be the reason for him to run, otherwise Third Way Medicare Reform is dead in the water.

Third Way predicted to meet Klein's fate

Dead-end way Tories mull future of health-care reform if Ralph exits scene



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Trump’s Project 2025 abolishes Medicare; We need to Fight Back and Expand it

By F. Douglas Stephenson

July 21, 2024

Source: Informed Comment




LONG READ


Gainesville, Florida (Special to Informed Comment; Feature) — The Heritage Foundation’s Project 2025, framed by former Trump administration staffers and secretly endorsed by Trump himself, proposes changes in Medicare benefits that could destroy Medicare as we know it. Instead, we must fight back and expand it.

On July 30, 1965, at the Harry S. Truman Presidential Library in Independence, Missouri, former President Harry S. Truman and his wife, former First Lady Bess Truman, became the first recipients of the new Medicare health insurance program. President Lyndon Johnson and the U.S. Congress enacted Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income or medical history and Medicaid for those whose incomes were below specific levels.

Medicare was a momentous act because it provided new health insurance for people ages 65 and older and the disabled regardless of income or medical history. In the 59 years since, Medicare has become living proof that public, universal health insurance is superior to private insurance in every way. Medicare is more efficient than private health insurance and is administered at a cost of 3 percent to 4 percent, as opposed to private, for-profit health insurance, which has administrative costs above 15 percent.

Following the successful 1965 grassroots campaign to enact Medicare, many believed that the dream of a full national, single-payer health insurance system that included all age groups, “Medicare for All”, was right around the corner. Unfortunately five decades later, Medicare still has not been expanded. Most of the changes have been contractions with higher out-of-pocket costs for beneficiaries and repeated attempts at privatization by Big Pharma, Big health insurance industry companies/oligarchs/profiteers and their champions in the White House and Congress.

Big insurance and Big Pharma continue opposing legislation for the new Medicare for All because these resistant, self-serving industries have the most to lose if their huge profits are redirected to direct patient care for all. Individual and corporate predators regard democracy, government and community as obstacles to their greed and avarice, always placing profits over individual patients, families and public health. It’s no wonder so many beholden members of Congress want to protect the interests of Big Insurance and Big Pharma.

WEALTH ADDICTION OF BIG HEALTH INSURANCE/BIG PHARMA/CONGRESSIONAL PROFITEERING COMPLEX:

“Money is like salt water. The more you drink, the thirstier you get”. Roman proverbs say that the more money a rich man has, the more driven he is to accumulate more. Limitless greed for money the Greek dramatists said, becomes a disease of the psyche. In the 388 B.C. play, “Ploutos”, Aristophanes writes that a person may become over-saturated with food….but no one ever has enough wealth. Wealth addiction is a greedy compulsion to obtain more and more wealth, and specifically obtain what belongs to others. The net effect is to injure others because it is adversarial/harmful to society as a whole.

Although health insurance affordability for the majority of US citizens still remains elusive, President Biden’s health insurance plan still wants to shift many more dollars into private, Wall Street insurance industry hands. The takeover of public health insurance, as with Medicare Advantage plans and others, by private Wall Street entities continues apace as Democrats/Biden propose to increase taxes and give it to the private profit insurance industry—the basic source of our profound administrative waste, along with the costly administrative burdens they place on the delivery system that requires large profits. Profiteering continues unabated as private insurance sells us services we don’t need/want , such as deductibles and other cost sharing, maintenance of narrow networks, requiring prior authorization with increased administrative costs, excessive ongoing paperwork/documentation requirements, all while avoiding paying for surprise bills and other denied benefits.

ABC News Video: “What to know about Project 2025”

PROFITEERING SURVEY FROM GOVERNMENT PROGRAMS: (data from ” BIG INSURANCE 2022: Revenues reached $1.25 trillion thanks to sucking billions out of the pharmacy supply chain – and taxpayers’ pockets”, Wendell Potter, HEALTH CARE-uncovered,02/23/2023)

1). Big Insurance revenues and profits have increased by 300% and 287% respectively since 2012 due to explosive growth in the companies’ pharmacy benefit management (PBM) businesses and the Medicare replacement plans called Medicare Advantage.

2). The for-profits now control more than 80% of the national PBM market and more than 70% of the Medicare Advantage market.

3). In 2022, Big Insurance revenues reached $1.25 trillion and profits soared to $69.3 billion.

4). That’s a 300% increase in revenue and a 287% increase in profits from 2012, when revenue was $412.9 billion and profits were $24 billion

5). More than 90% of health-plan revenues at three of the companies come from government programs as they continue to privatize both Medicare and Medicaid, through Medicare Advantage in particular.

6). Enrollment in government-funded programs increased by 261% in 10 years; by contrast commercial enrollment increased by just 10% over the past decade.

7). Commercial enrollment actually declined at both UnitedHealth and Humana.

8). 85% of Humana’s health-plan members are in government-funded programs; at Centene, it is 88%, and at Molina, it is 94%.

9). The big insurers now manage most states’ Medicaid programs – and make billions of dollars for shareholders doing so – but most of the insurers have found that selling their privately operated Medicare replacement plans is even more financially rewarding for their shareholders.

10). This is especially apparent when you see that the Big Seven’s combined revenues from taxpayer-supported programs grew 500%, from $116.3 billion in 2012 to $577 billion in 2022.

11). Changes in health-plan enrollment over the past decade show how dramatic this shift has been. Between 2012 and 2022
enrollment in the companies’ private commercial plans increased by 10%, from 85.1 million in 2012 to 93.8 million in 2022.

12). By comparison, growth in enrollment in taxpayer-supported government programs increased 261%, from 27 million in 2012 to 70.4 million in 2022.

13). Within that category, Medicare Advantage enrollment among the Big Seven increased 252%, from 7.8 million in 2012 to 19.7 million in 2022.

14). Nationwide, enrollment in Medicare Advantage plans increased to 28.4 million in 2022 (and to 30 million this year). That means that the Big Seven for-profit companies control more than 70% of the Medicare Advantage market.

MEANWHILE, AS BIG INSURANCE THRIVES:(data from Potter)

**27.5 million people remain uninsured in the United States. Up to 14 million more will lose their Medicaid coverage once the pandemic emergency period ends later this year.

**100 million of us – almost one of every three people in this country – now have medical debt.

**In 2023, U.S. families can be on the hook for up to $18,200 in out-of-pocket requirements before their coverage kicks in, up 43% since 2014 when it was $12,700.

**44% of people in the United States who purchased coverage through the individual market and (ACA) marketplaces were underinsured or functionally uninsured.

**46% of those surveyed said they had skipped or delayed care because of the cost.

**42% said they had problems paying medical bills or were paying off medical debt.

**Half (49%) said they would be unable to pay an unexpected medical bill within 30 days, including 68% of adults with low income,

**69% of Black adults, and 63% of Latino/Hispanic adults.

**In 2021, about $650 million, or about one-third of all funds raised by GoFundMe, went to medical campaigns. That’s not surprising when you realize that in the United States, even people with insurance all too often feel they have no choice but to beg for money from strangers to get the care they or a loved one needs.

**62% of bankruptcies are related to medical costs.

**Even as we spend about $4.5 trillion on health care a year, Americans are now dying younger than people in other wealthy countries.

**Life expectancy in the United States actually decreased by 2.8 years between 2014 and 2021, erasing all gains since 1996, according to the Centers for Disease Control and Prevention.

WENDALL POTTER CONCLUDES:
“The companies that comprise Big Insurance are vastly different from what they were just 10 years ago, but policymakers, regulators, employers, and the media have so far shown scant interest in putting their business practices under the microscope. Changes in federal law, including the Medicare Modernization Act of 2003, which created the lucrative Medicare Advantage market, and the Affordable Care Act of 2010, which gave insurers the green light to increase out-of-pocket requirements annually and restrict access to care in other ways, opened the Treasury and Medicare Trust Fund to Big Insurance. In addition, regulators have allowed almost all of their proposed acquisitions to go forward, which has created the behemoths they are today. CVS/Health is now the 4th largest company on the Fortune 500 list of American companies. UnitedHealth Group is now No. 5 – and all the others are climbing toward the top 10”

OPPOSING MEDICARE BY PRIVATIZING PUBLIC SERVICES:

The U.S. Congress/government permits private health insurance companies to exact large profit from its cItizens, Wall Street banks and investors who back Big Insurance turn public money into a bonanza of private riches. High health insurance costs are the result of a political decision to essentially allow Big Insurance to do what they want and charge whatever they want.

Fully backed by Wall Street, the for- profit, private insurance industry thoroughly dominates our national health insurance system and defines the basic concept and purpose of health insurance . The U.S. subscribes to a private business model of health insurance that defines insurers as commercial entities. Private insurers maximize profits by mainly limiting benefits, maximizing health policy premiums or by not covering people with health problems. Like all businesses, their goal is to make money. Under the addictive business model, the greed of casual inhumanity is built in and the common good of the citizens and nation is ignored; excluding the poor, the aged, the disabled and the mentally ill is sound business policy, since it maximizes profit .

INCREASED CORPORATE POWER/PRIVATIZATION OVER PUBLIC RESOURCES:

A new report from OXFAM, 01/24/24, “Inequality. Inc.”, describes how “around the world, corporate power is relentlessly pushing into the public sector, commodifying and segregating access to vital services such as education, water and healthcare, often while enjoying massive, taxpayer- backed profits.This can gut governments’ ability to deliver the type of high-quality, universal public services that can reduce inequality.

The stakes are huge. Essential services constitute trillion- dollar industries and immense opportunities for generating profit and wealth for rich shareholders. The World Bank and other development finance actors have prioritized private service provision, effectively treating basic services as asset classes and using public money to guarantee corporate returns rather than human rights. Private equity firms are snapping up everything from water systems to healthcare providers and nursing homes, amid a litany of concerns about poor and even tragic outcomes”.

OXFAMS “inequality Inc.” report further warns that ”privatization often entails giving corporations control over significant areas of policymaking, as well as access to public resources and capacity that could otherwise be dedicated to providing universal services and reducing inequality. Despite the promotion of privatization as a cost-saving measure, many contemporary arrangements such as PPPs and outsourcing can be highly costly to the state and require taxpayers to guarantee private sector profits. The fiscal risks of PPPs are particularly extreme, earning them the nickname ‘budgetary timebombs’. That such arrangements often place a high burden on public coffers and routinely cost more than public delivery undermines arguments that privatization is necessary because the public sector lacks sufficient resources.

Institutional investors are turning to PPPs and other forms, (eg., Medicare Advantage, ACOs) of privatized services to generate stable returns. Major development agencies and institutions, many of which have adopted policies that prioritize private provision of services, have found common ground with investors by embracing approaches that ‘de-risk’ such arrangements by shifting financial risk from the private to the public sector. This new ‘Wall Street Consensus’ reframes the ‘Washington Consensus’ in the language of contemporary development speak, and envisions the transformation of basic services such as education, healthcare and water into financial assets backed by public resources”.

STRATEGY OF PRIVATE INSURANCE INDUSTRY:

To protect and enhance high profits by opposing improved Medicare for All 2024, the private health insurance industry has mounted a huge campaign using myths, scare and fear tactics ever since ‘Obamacare’, the Affordable Care Act (ACA), was enacted in March, 2010. The U.S. health insurance industry lobbied Congress hard at that time to enact a requirement that most non-elderly Americans become compulsory customers of the private insurance industry and approve taxpayer financing of massive subsidies for that industry. The private insurance industry is very happy that with ACA, Americans are forced to purchase the product of their private industry plus give huge tax-financed subsidies to their industry in the amount of a half-trillion dollars per decade.

FEAR: The expedient health insurance industry seeks to protect high profits using scare/fear tactics against new and improved Medicare for All 2024 legislation. One tactic deliberately confuses the public by not telling individuals what would change if their private insurance is replaced by the new Medicare for All health insurance program. Lack of specificity and avoidance behavior promotes confusion, misunderstanding and great fear because it conflates loss of private health insurance with loss of their own physicians, other health professionals and hospitals. The for-profit health insurance industry knows full well that people are most interested in keeping their own doctors and that the new Medicare for All 2024 does not interfere with that. By conflating private health insurance with the direct provision of medical treatment itself, many patients are mislead into thinking they could lose all their health professionals. Fortunately, once folks understand that losing their expensive, for-profit private insurance plans is the only thing that will change, support for Medicare for All sharply increases. The huge profits of Big Insurance and Big Pharma are threatened once folks become aware of this tactic.

SOCIALIZED MEDICINE: Another industry scare tactic is to stoke public fear and confusion by conflating the “socialized medicine” label with single-payer, “socialized (public) health insurance”. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. The U.S. Veterans Administration is an example. In contrast, most European countries, Canada, Australia and Japan have ‘socialized health insurance’, not ‘socialized medicine’. The term “socialized medicine” is often used by the private insurance industry and politicians to manufacture frightening images of government bureaucratic interference in medical care. In countries with socialized health insurance, health and mental health professionals and patients often have more clinical freedom. This is in sharp contrast to the U.S., where private health insurance bureaucrats attempt to direct/interfere with care .

Manufactured confusion and fear of socialism by the health insurance industry and their political spokesmen impede the public’s ability to differentiate and thereby reduce support for Medicare for All . This allows the private health industry to successfully maintain control of the U.S. health care system for its own profitable purposes.

SEE “PLAYING THE ACE OF FEAR CARD” IN MMT SECTION BELOW: Playing “as if we can’t afford” M4A with the “ace of fear” card, opponents of M4A 2024 use the scary myth that large, confiscatory tax hikes will be needed to “pay for” M4A.

PREJUDICE AGAINST GOVERNMENT: Opposition to Medicare for All is also based on irrational fears, folklore/myth and general prejudice against government programs. Fear-mongering about waiting lists, bankrupt doctors and hospitals, and socialism is exactly the same fearful/false rhetoric used in the campaign to block LBJ’s original Medicare program in the mid-1960s. The Wall Street Journal then warned about “patient pileups,” and the American Medical Association mounted a campaign featuring Ronald Reagan that smeared Medicare as creeping socialism that would rob Americans’ freedom.

Unfortunately many government leaders from both political parties share the same ‘profits over public health’ ideology, even though the Covid-19 pandemic clearly showed how our economic system failed to serve our citizens by allowing these groups to privatize, sabotage, fragment and cripple our health, public health and other social services. No greater disconnect exists between the public good and private interests than in the U.S. system of for-profit health insurance. Using dark money, Big Insurance and Big Pharma are very powerful private interests that have shaped public policy in national health insurance and public health for the past 40 years.

U.S. SUPREME COURT: Strong support for the U.S.Supreme Court, ‘Citizens United’ decision, by unaccountable/unregulated large Big Insurance and Big Pharma corporations and ultra-wealthy individuals/families. is based on their Machiavellian understanding of the purpose of dark money in politics: to use dark money to change political outcomes to favor themselves, the 001% oligarchs and becomes a threat to democracy because its source is not made public. Dark money is corruption that erodes confidence and trust in local, state and national government and in both major political parties. It’s used to throw referendums and elections from which can come many of today’s social, economic, public health, mental health and environmental problems. Dark money is used to hide conflicts of interests and further enhance self promotion with bogus scientific controversies, fake news and fake grassroots campaigns.

REDUCE GOVERNMENT CAPACITY TO RESPOND: To reduce governments capacity to respond to public health problems/environmental crises such as Covid-19, single-payer national health insurance and other social services, these companies fund right-wing think tanks to attack public health/social policy. By presenting government as a threat to freedom, the distinguished writer for The Guardian(U.K.),George Monbiot, described how right wing groups and big business create a narrative by reframing responsible government as the “nanny state”, the “health police” and “elf ‘n’ safety zealots”. They dismiss scientific findings and predictions as “unfounded fears”, “risk aversion” and “scaremongering”. Public protections are recast as “red tape”, “interference” and “state control”.

Although some have negative feelings toward government, and examples of government inefficiency exist, the record of private health insurers is far worse. The only thing that exceeds government inefficiency is the private health insurance industry itself. Dozens of financial profiteering scandals have wracked private insurers and HMOs in recent years. Everyone should categorically reject myths about ‘Medicare for All’ that try to frighten seniors and others by telling them they will lose Medicare benefits under a new M4A program, that pointy-headed government bureaucrats will make medical decisions, determine the cost vs benefits of procedures, including age and quality of life considerations and medical personnel will be in short supply.

TRADITIONAL MEDICARE THREATENED BY NEW PRIVATE PROFITEERS: Private profit “Medicare Advantage” present new threat to Traditional Medicare.

WHAT IS MEDICARE ADVANTAGE? Medicare Advantage is a managed care program offering private health insurance plans as options to replace traditional Medicare. Medicare Advantage plans differ from traditional Medicare in that they are paid with capitation (per member), they are required to limit enrollees’ out-of-pocket spending and can offer extra benefits (e.g. gym memberships, $900 worth of groceries, dental benefits). They almost always offer prescription drug coverage and use a defined and often restricted network of providers that can require enrollees to pay more for out-of-network care. Utilization management techniques are used ,such as prior authorization, and they can also fund special programs such as rewards for beneficiaries to encourage healthy behaviors. The deceptively innocent hope is that these differences will lead to improved care at lower cost compared to Traditional Medicare.

In reality, “Medicare Disadvantage”is a better, more accurate name for the programs however, as insurance companies push Congress to corporatize all of Medicare, yet keep the name for the purposes of marketing, deception, and confusion.

Dismantling Medicare with Medicare Advantage: Over 50% of Medicare beneficiaries now have for-profit corporations in charge of their care through Medicare Advantage (MA). Insurance companies are paid handsomely for these plans, and much of that money goes to corporate profits instead of care. The companies running MA plans want to take over Medicare entirely, leaving patients with no option but to give their money to private insurers.

Denying Treatment: Investigations into claim denials in MA found that insurers were inappropriately denying treatments and tests that should be covered under Medicare. Physician surveys show that these practices often cause patients to suffer unnecessarily, and can even be life-threatening. In some cases, MA insurers were found to spend just seconds on each claim, and even denied claims using artificial intelligence instead of medical experts.

Deceiving Patients and Taxpayers: Reports from journalists, researchers, and government agencies have shown that health insurance companies like UnitedHealth and Cigna overcharge Medicare by giving patients exaggerated or entirely false diagnoses. Several companies have been fined, or sued, and agreed to large settlements. MA insurers are taking citizens tax dollars for conditions they aren’t even treating.

Bottom Line: Medicare Advantage is not the same Medicare program that Americans have come to know and love. The private insurance industry has spend millions on advertising in order to hide the ugly truth: their MA plans raid taxpayer funds and routinely fail to deliver the care that patients expect and deserve.

Terminate Medicare Advantage: Physicians for a National Health Program (PNHP), concludes tnat the Center for Medicare Services (CMS) should terminate the Medicare Advantage program. It would be far more cost-effective for CMS to improve traditional Medicare by capping out-of-pocket costs and adding improved benefits within the Medicare fee-for-service system than to try to indirectly offer these improvements through private plans that require much higher overhead and introduce profiteers and perverse incentives into Medicare, enabling corporate fraud and abuse, raising cost to the Medicare Trust Fund, and worsening disparities in care. These problems are not correctable within the competitive private insurance business model, and the Medicare Advantage program should be terminated.

MODERN MONETARY THEORY- MMT AND MEDICARE FOR ALL:

The US healthcare system is notorious for its high costs and below par outcomes. We already spend 18 percent of GDP on healthcare, and that is projected to reach 20 percent soon. This is approximately twice as much as our peers, other rich, developed, capitalist countries with no discernably better health outcomes (and even worse on a number of measures). Our excessive spending when compared to that of our peers can be attributed to the use of for-profit private insurance to pay for healthcare, higher pharmaceutical and provider costs, and higher administrative costs. Study after study has confirmed that prices and administrative costs in the US are out of line with those in the rest of the developed world, and especially compared to countries that have some type of a single-payer.

The Ace of Fear Card: Playing “as if we can’t afford” M4A with the “ace of fear” card, opponents of M4A 2024 use the scary myth that large, confiscatory tax hikes will be needed to “pay for” M4A. Economists at the Levy Institute of Economics of Bard College alert us how opponents of M4A typically warn of the high financial costs, and hence of prospective dangerously high government deficits. From the perspective of Modern Money Theory (MMT) however, these fear mongering arguments are beside the point and are a myth. A sovereign government’s finances are not like the budgeting by households and firms; the government uses the monetary system to mobilize the nation’s real resources and to move some of them to pursuit of public purposes, such as social welfare programs, public health, public health insurances, Medicare for All, etc. Whatever the financial costs, we already have a financial system that can handle them.

Distinguished Professor of Economics L. Randall Wray, Levy Economic Institute of Bard College and Yeva Nersisyan, Associate Professor of Economics at Franklin and Marshall College, Lancaster, PA, maintain that :“a sovereign government like the USA is not financially constrained; it spends by fiat, i.e., printing money, and/or through creating electronic computer entries in bank accounts and can neither run out of them nor save them for the future. What should constrain the spending of a sovereign government is the nation’s available real resources. Excessive spending, therefore, creates problems not in terms of higher government deficits and debt, but in terms of true inflation. Similarly, taxes are used not to finance government spending, but to withdraw demand from the economy, creating space for government spending to move resources to the public sector without causing inflation”.

Professor Wray notes that“the adoption of a single-payer system (replacing for-profit private insurers) would significantly reduce the resources devoted to our unusual way of paying for healthcare. It would eliminate the private insurance sector’s participation, reduce employers’ costs of administering healthcare plans, reduce the costs incurred by doctors and hospitals due to billing insurers as well as pursuing patients for uncovered costs, lower the costs of appealing denials, and cut costs associated with patients avoiding early treatment of diseases (because of the actual or expected out-of-pocket costs) that become chronic and expensive maladies. If M4A could control prices and lower administrative costs, we could spend significantly less on healthcare than we do currently, while expanding coverage to everyone. All else equal, if we were able to reduce our spending on healthcare to the level of our peers, we would be creating deflationary pressures, not inflation”.

Nersisyan and Wray estimate that “in the short term M4A could save about 3.7 percent of GDP while providing healthcare to the whole population. Even if we lowered healthcare spending by 3.7 percent of GDP, we would still be spending more on healthcare than all of our peers. “We believe our estimates are just the savings possible in the short term. In the long term, increased use of healthcare could reduce spending on chronic diseases. With universal access, cost controls, and elimination of a highly inefficient private insurance system, the single-payer system could shrink US spending on healthcare by much more, bringing us in line with other rich countries at about 10 percent of GDP.”

“Some will object that the savings largely accrue to the private sector, while the government will face additional costs. While it is true that the distribution of spending between the private and public sectors would change”, economist Wray assures us that. “there is nothing about government spending that necessarily makes it more inflationary than private spending. If private spending on healthcare costs falls by more than the increased government spending, the movement to single payer will be deflationary, not inflationary. Only a net increase in demand for resources would be inflationary.”

CONCLUSIONS:
The common good of our nation is ignored because the U.S. subscribes to a private business model for health insurance that defines insurers as commercial entities. Private health insurers maximize profits by limiting benefits or by not covering people with health problems. Like all businesses, their goal is to make money. Under this business model of health insurance, the greed of casual inhumanity is built in and the common good of the citizens and nation is ignored. Excluding many in the middle class, the poor, the aged, the disabled and the mentally ill is sound business practice policy since it maximizes profit.

Today we still have tens of millions of individuals without insurance, many more who are underinsured, many who have impaired access to their physicians and other health/mental health professionals because of insurer network restrictions, many who face financial hardship when health needs arise, and an outrageously expensive system due to the profound administrative waste of the insurers and the burden they place on the health care delivery system when immense profit is required. For example, statistics show that nearly 41% of adults (or nearly 100 million) are forced to get a medical loan to cover their health-care debt because they don’t have enough savings, and nearly 12% of them owe more than $10,000. Also, these data don’t take into account such forms of debt like credit cards or installments offered. When millions lost their jobs due to Covid-19, the dangers of connecting health insurance to employment also became painfully clear. Health insurance must not be tied to employment.

Almost none of these problems would exist if the government, instead of the private insurers, served us as a single-payer, health insurance financing authority. It is inhumane to allow consumer-directed, moral-hazard based private health policies to erect barriers to health care for millions of citizens with minimal or modest resources.

We now have several decades of experience with the conversion of health/mental health care into a business. Our health care is being rationed, with care guidelines determined by profitability and secrecy decided in private Wall Street corporate boardrooms. To realize large profits demanded by Wall Street investors, our health system must attract the healthy and turn away the sick, disabled, the poor, many of the old, and the mentally ill.

To maintain corporate control of U.S. health care insurance, our system is privatized and unregulated. Private, big insurance companies are in the business of making money, not providing full health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs (and immense profiteering ) are greater in the private health care insurance system, and even Medicare itself is weakened by having to work through the private system.

The USA is a country where health insurance for medical and mental health care is a function of socio-economic status. Everyone knows that this inhumane system should have been corrected long ago, but the death and illness ravages of the pandemic crisis makes it impossible to any longer avoid reality. We must immediately end our moral crime of having one of the the greatest health systems in the world, but only for those who can afford it. We must support the common principles that health care is a human right, must be free from corporate profit, and must be achieved through national legislation.

Let’s never forget that universal Medicare for All is a solid investment, not an expense, in and for our country by simply promoting a social service for universal access to affordable health care insurance for all. Aren’t we a society that cares enough to see that everyone receive the health care they need? That’s the basic purpose of Medicare for All. The 59 year history of our most successful national health insurance program, Medicare, provides one of the best arguments for expanding the program to cover everyone. It’s time to end inadequate and dangerous health insurance programs. Insist on real health insurance reform essential for all individuals and families.

American history is filled with examples of fundamental, democratic change brought about by successful mass action and public pressure against the counseling of the wealth addicted, neoliberal, privatization, 1% self-serving oligarchs/vested interest/profiteering/crowd. Professor of Economics L. Randall Wray notes that the US healthcare system still has significant gaps in coverage—all while facing the highest healthcare bill in the world. Dr. Wray convincingly argues that the underlying challenge for a system based on private, for-profit insurance is that basic healthcare is not an insurable expense. He concludes that It is time to abandon the current, overly complex and expensive payments system and reconsider single payer for all. Social Security and Medicare provide a model for reform.

Today, the very best way forward is, without ambivalence, avoidance behavior or any further delay, to immediately implement new legislation now filed in Congress, “The Medicare for All Act of 2023” House Bill (H.R. 3421) and Senate Bill (S. 1655) that would establish this long overdue reform.

President Harry S. Truman once said,”There is nothing new in the world except the history you do not know”. Attempts to transfer ownership and control of economic programs/services/financial resources from the government into private, greedy hands have existed in many societies for thousands of years. Father Lactantius, c.250-c.326, an early Christian author and advisor to the Roman Emperor Constantine I, wrote in “ The Divine Institute”, a timely piece about Roman society that well applies to 21st century USA society:

In order to enslave the many, the greedy began to appropriate and accumulate the necessities of life and keep them tightly closed up so that they might keep these bounties for themselves. They did this not for humanity’s sake which was not in them at all but to rake up all things and products of their greed and avarice. In the name of justice, they made unfair and unjust laws to sanction their thefts and avarice against the power of the multitude. In this way they ruled as much by authority as by strength of arms and overt evil.

LINKS: Full text U.S.House of Representatives – H.R. 3421

Full text U.S. Senate – S. 1655

Wall Street 'overjoyed' as Biden lets Medicare Advantage insurers off easy

Jake Johnson, Common Dreams
April 10, 2023

UnitedHealth Group, a dominant force in the lucrative Medicare Advantage market, has seen its stock jump over the past week as Wall Street analysts and investors embrace the Biden administration's decision to delay reforms aimed at tackling abuse in the privately run, government-funded health program.

STAT reported late last week that "Wall Street was overjoyed" by the announcement from the Centers for Medicare and Medicaid Services (CMS), which said it would phase in changes to the model that dictates how much government funding Medicare Advantage insurers receive to cover patient care.

Instead of implementing the changes all at once, the Biden administration will roll out the reforms over a three-year period, allowing Medicare Advantage insurers to continue overbilling the federal government in the meantime.

Recent federal audits and investigative reports have detailed how Medicare Advantage plans overcharge the government to the tune of billions of dollars a year by making patients appear sicker than they are, piling on diagnoses with little to no supporting documentation. Medicare Advantage plans also frequently deny necessary care and use algorithms to prematurely end coverage.

In addition to delaying full implementation of its reforms, CMS—which has faced aggressive lobbying from UnitedHealth and other major Medicare Advantage players in recent weeks—announced it would boost payment rates for Medicare Advantage plans by 3.3% in 2024—a larger-than-expected increase.

CMS said Medicare Advantage payments would rise by nearly $14 billion next year under the new plan.

As STAT's Bob Herman noted, "health insurance companies that participate in Medicare Advantage will retain billions of extra taxpayer dollars next year" thanks to the Biden administration's changes, which drew criticism from progressive lawmakers and some policy experts.

"The phased-in approach will continue to reward those insurers with the most abusive practices over the next two years," warned Mark Miller, executive vice president of healthcare for the philanthropy Arnold Ventures.

Herman reported that following the CMS announcement, "investors raced to buy stocks of the largest Medicare Advantage insurers, including UnitedHealth, Humana, CVS Health, Elevance Health, and Centene." STAT cited one analyst estimate suggesting that UnitedHealth Group could see $900 million in additional profit next year thanks to the CMS policy revisions.


"It was 'a sigh of relief' for the industry, according to Jailendra Singh, a healthcare stock analyst at Truist Securities," Herman wrote. "Chris Meekins, a health policy analyst at Raymond James, called the White House's move 'a clearing event for the space.'"UnitedHealth, Cigna, Humana, CVS/Aetna, Elevance Health, Centene, and Molina have seen their combined revenues from taxpayer-funded programs like Medicare Advantage soar from $116.3 billion in 2012 to $577 billion in 2022, according to a recent analysis

by Wendell Potter, a former Cigna executive who now heads the Center for Health and Democracy.

Those companies have been at the forefront of what The New York Times recently described as a "lobbying frenzy" on Capitol Hill, a blitz that appears to have influenced the Biden administration's decision to go easy on Medicare Advantage despite promising bold reforms.

The Times noted that the administration's earlier proposals to revise the Medicare Advantage risk-adjustment model "unleashed an extensive and noisy opposition front, with lobbyists and insurance executives flooding Capitol Hill to engage in their fiercest fight in years."

"The largest insurers, including UnitedHealth Group and Humana, are among the most vocal, according to congressional staff, with UnitedHealth's chief executive pressing his company's case in person," the newspaper reported. "Since the proposal was tucked deep in a routine document and published with little fanfare in early February, Medicare officials have been inundated with more than 15,000 comment letters for and against the policies, and roughly two-thirds included identical phrases from form letters."

The Better Medicare Alliance, a lobbying organization backed by top Medicare Advantage insurers, purchased a Super Bowl ad decrying the Biden administration's earlier reform proposals as an effort to "cut" Medicare Advantage.

Rep. Pramila Jayapal (D-Wash.), chair of the Congressional Progressive Caucus, said in a statement late last week that she was disappointed by the Biden administration's decision to weaken its reforms in the face of industry pressure.

"It is now clear that Medicare Advantage is simply a profiteering venture that hurts patient care," said Jayapal. "Without a complete overhaul, it will be impossible to stop bad actors. These plans have spent years scamming seniors and overcharging the government to pad their own profits. We were on the cusp of immediate reform when the Biden administration proposed fixes to stop price gouging by insurance companies."

"Sadly," she added, "health insurance companies used taxpayer dollars meant for medical care to instead buy Super Bowl commercials and desperately lobby to stop these changes that would cut down on their profiteering."

How Medicare for All Would Affect Union Health Plans

Medicare for All would save IUPAT members $4,868 to $7,866 per year.

3P ORIGINAL REPORT NO.019

BY Matt Bruenig and Jon Walker
August 17th, 2020

Download Full Report


In the political discourse around health care reform, commentators frequently raise concerns about the effect of any given reform on union health plans. In this paper, we use data provided by the International Union of Painters and Allied Trades (IUPAT) to determine what the net financial impact of implementing Medicare for All or Bidencare would be on their members. In short, we find that Medicare for All would save their members $4,868 to $7,866 per year while Bidencare could save them $676 to $3,253 per year if they take advantage of new individual exchange subsidies.
Union Health Plans

In a normal employer health plan, an individual firm provides insurance to the workers employed by the firm. In a union health plan, also known as a multiemployer plan or a Taft-Hartley plan, a union and various employers establish a separate trust fund that jointly administers an insurance plan. During collective bargaining, the union agrees to forego wages so that the employers can contribute money to the trust fund, which then uses that money to provide health benefits to the union’s workers.



This structure has a few main advantages not found in single-employer plans. First, the larger size of multiemployer plans allows them to be more administratively efficient and allows them to negotiate better rates from third-party insurers. Second, in industries where workers frequently move between firms, such as the construction industry where IUPAT represents workers, the multiemployer nature of the plans means that workers can retain coverage even as they move from job to job. Lastly, unions can use the enticement of a multiemployer plan to assist in organizing workplaces that are not currently unionized.

But these advantages don’t insulate the plans from the general problems of the overall healthcare system. Ever-escalating healthcare prices have consistently increased the per-member costs of the funds, requiring unions to continually forego wage increases in order to free up money for employers to contribute to the funds. Plan members also face the prospect of dropping their insurance or having to pay hefty out-of-pocket premiums if they lose their job, have their hours cut, or change jobs to an employer who does not participate in the multiemployer plan.

Multiemployer plans are also uniquely vulnerable to macroeconomic shocks that cause large amounts of prolonged unemployment, such as the shock coinciding with the coronavirus pandemic. This is because many multiemployer plans base eligibility for benefits on how many hours a member worked in the last quarter or even sometimes in the last calendar year. This lagging eligibility criteria means that, during a mass disemployment event, the funds stop receiving employer contributions even though their members continue to be eligible for benefits based on their prior work record. When this happens, fund reserves are quickly depleted, threatening the solvency of the health plan.
Medicare for All

In order to determine the effect of moving to a Medicare for All system, we used detailed wage and health plan information from three IUPAT locals and compared the status quo arrangement to what would prevail under Medicare for All. The results are summed up in the following graph.


Bidencare

We did the same thing with the Bidencare proposal. Unlike Medicare for All, the Bidencare proposal lacks a number of key details, such as the precise sliding scale that will be used to determine exchange subsidies and what the employer shared-responsibility payment will be. We filled in those gaps with reasonable guesses in order to produce the graph below.



This graph assumes that the union and employers agree to stop providing health insurance so that the workers can buy an individual exchange plan using Biden’s proposed individual exchange subsidies.
Conclusion

Combining the Medicare for All and Bidencare graphs together producesthe following graph.



As a historical matter, it was smart for unions to take advantage of the Taft-Hartley Act to create multiemployer union health plans for their members. One of the things that gets lost in the discussion about healthcare reform is how similar Medicare for All is to these union plans. What unions recognized long ago is that it is much better for workers to create a central healthcare fund that many employers contribute into than to have a bunch of independent plans organized within each company. Medicare for All is just the logical extension of this insight to the whole economy. It is, in a sense, just one big multiemployer fund.

In light of the coronavirus catastrophe and the objective superiority of Medicare for All to existing union health plans—in terms of cost, solvency, and continuity of coverage—we believe that unions like IUPAT should take a stance in favor of Medicare for All for the benefit of their own members and the working class generally.


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FOR PROFIT HEALTHCARE U$A

How the nation's largest oxygen distributor became a multibillion-dollar Medicare scofflaw

Photo by Alexander Grey on Unsplash
man in blue hoodie wearing eyeglasses

Peter Elkind andProPublica

November 13, 2024

Reporting Highlights
Decades of Misbehavior: Lincare has repeatedly landed on Medicare’s equivalent of probation; the company has a dismal history of exploiting the government and ailing patients.
Too Big to Ban: Despite Lincare’s track record, Medicare, which provides most of the company’s revenues, has never sought to bar the company from the Medicare system.
Tolerating Wrongdoing: Faced with $60 billion a year in fraud, Medicare spends millions chasing companies but accepts penalties that are only a fraction of the profits made on misbehavior.

These highlights were written by the reporters and editors who worked on this story.

For Lincare, paying multimillion-dollar legal settlements is an integral part of doing business.

The company, the largest distributor of home oxygen equipment in the United States, admitted billing Medicare for ventilators it knew customers weren’t using (2024) and overcharging Medicare and thousands of elderly patients (2023). It settled allegations of violating a law against kickbacks (2018) and charging Medicare for patients who had died (2017). The company resolved lawsuits alleging a “nationwide scheme to pay physicians kickbacks to refer their patients to Lincare” (2006) and that it falsified claims that its customers needed oxygen (2001). (Lincare admitted wrongdoing in only the two most recent settlements.)

Such a litany of Medicare-related misconduct might be expected to provoke drastic action from the Department of Health and Human Services, which oversees the federal health insurance program that covers 1 in 6 Americans. Given that most of Lincare’s estimated $2.4 billion in annual revenues are paid by Medicare, HHS wields tremendous power over the company.

Sure enough, as part of the 2023 settlement, HHS placed Lincare on the agency’s equivalent of probation, a so-called corporate integrity agreement. The foreboding-sounding document includes a “death penalty” provision: Any “material breach” of the probation agreement, which runs for five years, “constitutes an independent basis for Lincare’s exclusion from participation in the Federal health care programs.” Such a ban could effectively kill Lincare’s business.

That sounds dire. Except that before that corporate integrity agreement was signed in 2023, Lincare was under the same form of probation, with the same death penalty provision, from 2018 to 2023, and violated its terms. From 2006 to 2011, Lincare was similarly on probation and also violated the terms, according to the government. And before that — well, you get the picture. Lincare has been on probation four times since 2001. And despite a pattern not only of fraud, but of breaking its probation agreements, Lincare has never been required to do more than pay settlements that amount to pennies relative to its profits.

This is not an aberration. While HHS routinely imposes the death penalty on small operations, it has never barred a national Medicare supplier like Lincare from continuing to do business with the government. Some companies, it seems, are too big to ban.

Lincare’s lengthy record of misbehavior isn’t a surprise to people in the medical equipment business. What is surprising is the federal government’s willingness to pull its punches with a company that has fleeced taxpayers and elderly customers again and again.

Federal officials have never pursued the company executives who oversee this behavior even though two of them, Chief Operating Officer Greg McCarthy and Chief Compliance Officer Jenna Pedersen, have worked at Lincare through all four of the company’s probationary periods. No one has faced criminal charges for activity the government’s own investigators deemed fraud.

Medicare has continued to pay Lincare billions even as many of the company’s customers revile it. Evaluations on customer-review websites are lacerating, and complaints to state attorneys general abound. On the Better Business Bureau’s website, 888 reviewers gave Lincare an average score of 1.3 out of 5. They cite dirty and broken equipment, charges that continue even after equipment has been returned, harassing sales and collection calls, and nightmarish customer service. As one person wrote in April, Lincare is “running a scam where they have guaranteed income” and “the customer can’t do a thing.”

HHS has always been reluctant to cut off big suppliers. Medicare’s first objective is to make sure nothing interrupts the flow of medications, devices and services to beneficiaries. And were HHS to seek to ban Lincare, the company would surely launch a long, costly legal war. But even if the cost of such combat reached many millions of dollars, it would still be a tiny fraction of the amount lost to fraud, which is yet another contributor to the soaring medical costs that bedevil the country. “This is taxpayer money,” said Jerry Martin, a former U.S. attorney who represented an ex-Lincare executive in a whistleblower suit against the company. “We need to pay people that don’t have four corporate-integrity agreements.”

Weak enforcement is not the only problem. Lincare is paid to rent oxygen equipment to patients, with HHS covering most of the monthly bills. But those rental fees often add up to many times what it would cost simply to buy the equipment. “If this were a rational country,” Bruce Vladeck, who ran Medicare from 1993 to 1997, told ProPublica, “the government would buy a million [oxygen] concentrators and pay Amazon or somebody to deliver them.”

In a seven-month investigation, ProPublica examined how Medicare’s largest provider of home medical equipment has managed to take advantage of its customers for a quarter of a century while fending off meaningful enforcement. ProPublica interviewed more than 60 current and former employees and executives, Medicare and Justice Department officials, patient advocates, and health care experts. ProPublica also reviewed dozens of court cases involving Lincare and thousands of pages of internal company documents, sales presentations and emails.

The investigation reveals a dismal picture of a company with a sales culture that depends on squeezing infirm and elderly patients and the government for every penny. Lincare employees are pressured to sell — whether a customer needs a product or not — on pain of losing their jobs.

And the company’s record of misbehavior and conflict extends far beyond its sales and billing practices. Lincare has paid $9.5 million in settlements for data breaches and mishandling patient and employee records. It has faced claims of violating wage rules, harassing customers with sales and collection calls, and tolerating racist comments to an African American employee. (Lincare lost the latter suit at trial and is appealing.) The company has repeatedly sparred in court with former executives, including a 2017 suit in which longtime executive Sharon Ford claimed that the company had cheated her out of a $1 million bonus. (A judge ruled in favor of Ford at trial before the case was overturned on appeal.) Ford testified that Lincare had earned an industry reputation as “The Evil Empire.” And when Lincare’s CEO, Crispin Teufel, resigned last year to become CEO of a rival company, Lincare sued him for breach of contract and misappropriating trade secrets. Teufel ultimately admitted to downloading confidential company records and was blocked from taking the new job. (Teufel did not respond to requests for comment. His replacement, Jeff Barnhard, took over as Lincare’s CEO in July 2023.)

Lincare declined multiple requests to make executives available for interviews. After ProPublica provided a lengthy document listing every assertion in this article, along with separate such letters to executives McCarthy and Pedersen, the company responded with a three-paragraph statement. It asserted that Lincare is “committed to delivering high-quality and clinically appropriate equipment, supplies, and services” but acknowledged “missteps in the past.” The company said its “new leadership” had “commenced a comprehensive review of our policies and procedures to help ensure we are complying fully with all state and federal regulations” and that “investments and enhancements we have made over the last several months will help prevent these issues from repeating in the future.” Lincare did not respond to follow-up questions requesting examples of the steps the company says it’s taking, including whether it has terminated any executives as part of this push.

When ProPublica asked a top Medicare enforcer why Lincare had eluded banishment, her answer suggested she views probation as a continuing ed class rather than a harsh punishment. “It’s like taking a college course,” said Tamara Forys, who is in charge of administrative and civil remedies for HHS’ Office of Inspector General. “At the end of the day, it’s really up to you to change your corporate culture and to study, to learn to pass the class … to embrace that and take those lessons learned and move them forward.” A spokesperson for the Centers for Medicare and Medicaid Services, which runs Medicare, declined to comment on Lincare but said the agency “is committed to preventing fraud and protecting people with Medicare from falling victim to fraud.”

There’s little incentive to refrain from misbehaving in an environment that tolerates bad behavior, said Lewis Morris, who was chief counsel to HHS’ Office of Inspector General from 2002 to 2012. “As long as that [settlement] check is less than the amount you stole, it’s a good business proposition."

Indeed, Lincare has counted on the government’s tepid response, two former company executives told ProPublica. Top management, they said, responds to fraud warnings by conducting a cost-benefit analysis. “I’ve sat in meetings where they said, ‘We might have $5 to $10 million risk — if caught,’” said Owen Kirk Staggs, who ran one of Lincare’s businesses in 2017 and fell out with the company. “‘But we’ve made $50 million. So let’s go for it. The risk is worth the reward.’”

Libby, Montana, provides a glimpse of the way Lincare operates. Oxygen is an urgent need in this mountain town of 2,857. Libby suffers from the lingering effects of “the worst case of industrial poisoning of a whole community in American history,” in the words of the Environmental Protection Agency. An open-pit vermiculite mine, which operated from 1963 to 1990, coated the area — and residents’ lungs — with needle-like asbestos fibers. More than 2,000 Libby citizens have been diagnosed with respiratory diseases since then; some 700 have died.

Hundreds of ailing residents relied on Lincare for home concentrators, which provide nearly pure oxygen extracted from room air. Medicare and Medicare Advantage plans (which the government also funds) covered 80% of the monthly rental of about $135; patients paid the remaining 20%.

In 2020, Brandon Haugen noticed something suspicious in Lincare’s bills. Haugen was a customer service representative at the company’s local distribution site, one of 700 such locations around the country. (Lincare serves 1.8 million respiratory patients in 48 states.)

Lincare was allowed to charge patients and their insurers for a maximum of 36 months under federal rules. After that point, patients could use the equipment without further charge. Lincare, however, kept billing local patients and their Medicare Advantage plans far beyond 36 months — in some cases, for years. To Haugen, this looked like fraud.

Haugen conferred with center manager Ben Montgomery. The two, who had grown up in the area, had been buddies since seventh grade, after getting to know each other at summer Bible camp. Then 38, earnest and just beginning to gray out of their boyishness, the two men were concerned. The patients the men dealt with were their neighbors.

A regional Lincare manager assured them that charging beyond 36 months for Medicare Advantage patients “is the correct way to bill.” Skeptical, Montgomery raised the issue with Lincare’s headquarters in Clearwater, Florida. Lincare’s compliance director told him, according to Montgomery, that “it’s the patients’ problem to fix it if they want it to stop”; that was “just how it worked.” Further questions, sent to Lincare’s chief compliance officer, Pedersen, went nowhere. “It seemed pretty obvious they were well aware of this,” Montgomery told ProPublica. “For me, these were my customers that you were screwing over.”

Among them was Neil Bauer, now 80, who lives in a ramshackle house “out in the boondocks,” as he put it, 38 miles southeast of Libby. Bauer spent his career as a barber, head of investigations for the county sheriff’s department and a member of the local school board. He’s been on oxygen for more than a decade and quickly gets short of breath. “I can’t do stuff so much now,” he said. His wife is on oxygen, too. “We just have a sick family,” Bauer said.

Lincare had kept billing Bauer for his concentrator for seven years after it was supposed to stop. The monthly copays weren’t huge, but they added up to $2,325 that he shouldn’t have been charged over that period, a daunting sum for Bauer, who lives on a fixed income — and a hefty mark-up over the cost of the equipment, which can be purchased online for $799. For its part, Medicare Advantage paid Lincare $9,299 for Bauer’s concentrator during this period, along with another $5,760 for the months Lincare was legally permitted to bill. All told, the rental payments to Lincare, during authorized and unauthorized periods, were $16,547 for that one $799 piece of equipment. “We paid forever,” said Bauer. “Never was I told that we could have one without having to pay anything.”

Haugen and Montgomery studied billing records. Among the customers in their tiny office, Lincare was improperly charging at least 33 people and their Medicare plans. The two began to wonder how far this problem extended. An employee in Idaho confirmed the same practice was occurring there. “In my mind,” Montgomery said, “I went, ‘This is Libby, Montana. Multiply that by every center in the country. This is obviously a lot bigger deal.’”

Montgomery and Haugen had seen enough. On Jan. 18, 2021, they emailed a joint resignation letter to Lincare’s top management, recounting their concerns about billing that “likely affects thousands of patients company wide.” Citing the lack of response from corporate officials, they wrote, “we can only conclude that this is a known issue that is being covered up by Lincare.”

Haugen had 10 children. Montgomery had four. Neither man had another job lined up. “Had this not happened,” said Montgomery, who had been at the company for 13 years, “I would have seen myself retiring from Lincare.”

Instead, they became whistleblowers. They retained a law firm and sued Lincare in Spokane, Washington, the site of Lincare’s regional headquarters. After federal prosecutors decided to back the case, Lincare settled in August 2023. The company admitted to overbilling Medicare plans and patients across the country for years and paid $29 million to settle the matter, with $5.7 million of that going to Montgomery, Haugen and their lawyers. Dan Fruchter, the assistant U.S. attorney leading the government’s case, told ProPublica that the overbillings likely involved “tens of thousands” of patients.

Lincare agreed to its fourth stint of probation with HHS; the new corporate-integrity agreement took effect on the day after the previous one expired. The conduct Montgomery and Haugen flagged had gone on for years while the company was already on probation. But Lincare got the government lawyers to agree that nobody would try to impose the Medicare death penalty. Lincare asserted in the settlement that it had installed software (which it did only after learning of the government investigation) that will prevent billing beyond 36 months. Lincare promised to ensure “full and timely” compliance with the agreement and prevent future wrongdoing.

Medicare fraud, including in the “durable medical equipment” category that Lincare operates in, has long been an intractable problem. It cost the U.S. Treasury an estimated $60 billion in 2023 alone.

The government deploys large sums to try to stop it. HHS’ inspector general’s office has a $432 million budget and a staff of 1,600. Those resources are effectively extended by whistleblowers — most of the cases against Lincare have been such suits — who can receive a percentage of a civil settlement if they reveal wrongdoing, and by federal prosecutors, who can also bring cases or join those filed by whistleblowers. Last year HHS recovered $3.2 billion from fraudulent schemes.

But the agency’s enforcers have wielded their biggest deterrent almost entirely against small perpetrators. In 2023, they banned 2,112 small firms and individuals from Medicare reimbursement.

HHS hasn’t done the same with companies that operate on a national scale. Forys, the agency enforcer, said she worries that expelling a big provider from Medicare could leave customers in the lurch. In April, Inspector General Christi Grimm defended her office’s work in congressional testimony but also asserted that its resources are inadequate. A lack of staff keeps it from even investigating “between 300 and 400 viable criminal and civil health care cases” annually, she testified, as well as more than half the fraud referrals from Medicare’s outside audit contractors.

A different reason for going easy on big companies was suggested by Vladeck, the former Medicare chief. Seeking to bar a large supplier for repeatedly violating probation would require exhaustive documentation and years of litigation against squadrons of well-paid corporate lawyers. As a result, Vladeck said, “there’s a real incentive, from a bureaucratic point of view, to just slap their wrist, give them a kick and make them apologize. … It’s a cost of doing business.”

There are steps enforcers could take, but almost never do, that would make companies take notice, according to Jacob Elberg, a former federal prosecutor who is now a professor at Seton Hall Law School. (Among his publications is a 2021 law review article titled “Health Care Fraud Means Never Having to Say You’re Sorry.”) Elberg’s research shows that HHS and prosecutors tend to negotiate far smaller civil settlements than the law allows, and they rarely prosecute company executives. They also almost never take cases to trial. In short, enforcers have long signaled to companies that they’re looking for a smooth path to a cash payment rather than a stern punishment for a company and its leaders. “It is generally a safe assumption,” Elberg said, “that the result will be a civil settlement at an amount that is tolerable.”

For its part, Congress may soon be weighing a new law that would reshape how the oxygen industry is paid by Medicare. But rather than clamp down on corporations, the legislation seems poised to do the opposite. A new bill called the SOAR (Supplemental Oxygen Access Reform) Act would hand companies like Lincare hundreds of millions more, by raising reimbursement rates and eliminating competitive bidding among equipment providers. Advocates say the legislation will help patients by making some forms of oxygen more available and improving service. But along the way it will reward Lincare and its rivals.

Congress has a history of treating oxygen companies generously. For years, lawmakers set Medicare reimbursements for oxygen equipment at levels that even HHS, in 1997, characterized as “grossly excessive.” Over the succeeding decade and a half, Lincare took advantage, snatching up hundreds of small suppliers and becoming the industry’s largest player.

In 2006, under pressure to reduce costs, Congress approved steps to curb oxygen payments, including the introduction of competitive bidding and the 36-month cap on payments for equipment rentals. But even those strictures were watered down after the industry poured money into political contributions and lobbyists, who warned that cuts would harm elderly patients.

Lincare compensated by amping up strategies that generated profits, with little apparent regard for Medicare’s rules, which say it will reimburse costs for equipment only when there is evidence of “medical necessity.” The company aggressively courted doctors and incentivized sales, through bonuses the company paid for each new device “setup.” According to a 2016 commission schedule, reps could earn $40 for winning an order for a new sleep apnea machine, $100 for a new oxygen patient and $200 for a noninvasive ventilator. The entire staff of each Lincare center could receive a small bonus for signing up a high percentage of new patients for automatic monthly billing. Patients who refused auto-billing, a company document advised, should be warned they might face “collection activity” and service cutoffs. “Sales is our top priority!” declared a 2020 PowerPoint to train new hires.

Once it had a customer, Lincare would pitch them more costly products and services. One way Lincare did this was through a program called CareChecks. Promoted as a “patient monitoring” benefit, CareChecks were aimed, according to a company presentation, at generating “internal growth.” If a patient exhibited a persistent phlegmy cough, Lincare could persuade their doctor to prescribe a special vibrating vest to loosen chest mucus. Nebulizer patients might be candidates for home oxygen. Patients using apnea devices were potential candidates for ventilators. “We’d make patients think we were coming in clinically to assess them,” a former Lincare manager said, “when really it was to make money off of them.”

Selling replacement parts could also be lucrative. At Lincare call centers that sold items like hoses, masks and filters for CPAP machines (used to treat apnea), hundreds of commissioned agents in Nashville, Tennessee, and Tampa, Florida, were equipped with programs displaying what items each patient was eligible for under Medicare. By law, patients had to request replacement parts. But frequently, that wasn’t what happened, according to Staggs, who oversaw the CPAP business in 2017. He discovered that top salespeople, whose bonuses could total $8,000 a month, averaged just a few minutes on the phone per order. That wasn’t nearly enough time to identify what items, if any, customers actually needed. Staggs listened to recorded calls and found that, after reaching customers, agents often placed them on hold until they hung up, then ordered them every product that Medicare would cover.

At Lincare, results were closely tracked and widely shared in weekly emails displaying the best and worst performers in each region. Notes taken by one manager show supervisors’ performance demands during weekly conference calls: “Unacceptable to miss goal … stop the excuses … If this is not being done, wrong [center manager] in place … If you’re not getting O2 and not getting Care Checks — you shit the bed. Stop accepting mediocre, lazy responses ….”

“If we didn’t meet our quota, they were going to chop our heads,” said former Illinois sales rep Sandra Gauch, who worked for Lincare for 17 years before joining a whistleblower suit and quitting in 2022.

One salesperson was so fearful of missing her quota, according to Gauch, that she signed her mother up for a ventilator that she didn’t need. A company audit in 2018 found that only 10 of 56 ventilator patients at one center were using them consistently. Some patients hadn’t used their devices for years. Yet Lincare kept billing Medicare.

Only one thing mattered as much as maximizing new equipment rentals, according to former employees and company documents: minimizing customers’ attempts to end rentals. A call to retrieve breathing equipment meant that it was no longer wanted or being used, and Lincare was supposed to retrieve it and promptly stop billing Medicare and the patient. The person’s health might have improved. They might have gone into the hospital — or died. The reason didn’t matter; at Lincare, “pickups” were a black mark, deducted from employees’ performance scores, jeopardizing their bonuses and jobs.

As a result, employees said, such requests were dreaded, delayed and deterred. Clinical staff were sent to “reeducate” customers to keep using their devices. Patients were told they’d need to sign a form stating they were acting “against medical advice.”

Lincare managers made it clear that pickups should be discouraged. In a 2010 email, an Ohio center manager instructed subordinates: “As we have already discussed, absolutely no pick-ups/inactivation’s are to be do[ne] until I give you the green light. Even if they are deceased.” In 2018, an Illinois supervisor emailed her deputies that pickups were barred without her explicit approval: “Not even Death that I don’t approve first.”

In February 2022, Justin Linafelter, an area manager in Denver, responded to the latest corporate email celebrating monthly “Achievement Rankings” for oxygen sales by pointing out that almost all of the centers atop the rankings had at least 150 “pending pickups,” customers who weren’t using their equipment but whom the company appeared to still be billing. “Some of these centers are just ignoring pickups to make this list.”

That was only one of Linafelter’s concerns. In July of that year, he emailed headquarters, saying he no longer had “the resources to be successful at my job.” The customer service staff in Denver had been cut in half, Linafelter explained, and he’d been barred from hiring replacements. Denver’s remaining staff was “at a point of exhaustion,” threatening patient care.

The morning after Linafelter expressed concerns to Lincare in 2022, he was summoned to a conference call with the head of HR and fired, for what he was told was a “corporate restructuring.” Linafelter, who had worked at Lincare for nine years, said, “I got thrown away like a piece of trash.”

Other former employees offer similar accounts. In 2020, Jillian Watkins, a center manager in Huntington, West Virginia, repeatedly alerted supervisors that Lincare was improperly billing for equipment that patients weren’t using. Lincare blocked her from firing a subordinate who’d falsified documents supporting the charges, then fired Watkins, citing “inadequate direction and leadership.”

Then came a series of turns. Pedersen, the chief compliance officer, effectively confirmed Watkins’ assertions, belatedly alerting the government about $486,000 in improper billings by Lincare. But Pedersen blamed the billings on Watkins, writing to Medicare that the company had “terminated” her to “prevent [the problem] from recurring.” After Watkins sued, Pedersen admitted in a deposition that Watkins’ firing “had nothing to do with the overpayment.” In April 2024, a federal judge ruled that Watkins had presented “a prima facie case of retaliation.” The suit was privately settled in mediation.

Staggs, too, was ousted, he said, after he warned top Lincare executives about improper practices at the CPAP call centers. Staggs emailed a Lincare HR officer: “Patients are being shipped supplies that they never have ordered. … This is fraud and I have gotten zero support or attention to this matter when I raise the issue to my leadership.” Only months after starting, he was fired in November 2017. He later filed a whistleblower suit; Lincare denied wrongdoing. After the U.S. attorney’s office in Nashville declined to join the case in 2022, Staggs withdrew the action.

Staggs’ account of improper billings matches an industry pattern that appears to continue to this day. In a 2018 report, HHS’ inspector general estimated that Medicare had paid more than $631 million in improper claims for CPAP and other supplies over a two-year period. Another HHS analysis identified an additional $566 million in potential overpayments for apnea devices.

The agency’s oversight “was not sufficient to ensure that suppliers complied with Medicare requirements,” the 2018 report concluded. Six years later, HHS has not taken public action against Lincare relating to CPAPs.

Today, fraudulent billing among Medicare equipment providers remains a “major concern,” according to the inspector general. The agency says it continues to review the issue.


Doris Burke contributed research.

Democrats want to allow 60-year-olds into Medicare as part of Biden's infrastructure package

jzeballos@businessinsider.com (Joseph Zeballos-Roig) 

© Getty/Pool Rep. Pramila Jayapal. Getty/Pool

Democrats are attempting to expand Medicare as a part of Biden's infrastructure plans.

"Medicare expansion means more coverage for more people," a top Democrat said.

The effort may be derailed by Joe Manchin, who says he opposes enlarging Medicare access.

The latest Democratic battle to expand Medicare access is under way.

A group of more than 150 House Democrats from the progressive and centrist wings of the party are launching a campaign to include an expansion of Medicare in President Joe Biden's infrastructure plan, The New York Times reported.

They sent a letter on Thursday to Biden and Vice President Kamala Harris arguing to widen the federal health program so it includes a broader range of Americans, along with growing the range of benefits provided so it includes dental, vision, and hearing aids.

"Medicare expansion means more coverage for more people - and by finally allowing Medicare to negotiate drug prices, it's at a lower cost for taxpayers," Chair of the Congressional Progressive Caucus Pramila Jayapal, a leader of the effort, said in a Friday tweet. "Let's get this done."


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The plan would cut the eligibility age from 65 to 60, adding roughly 23 million Americans into the government health insurance program. The group projects it would amount to $200 billion over a decade. They say the price tag would be offset with another proposal: empowering Medicare to negotiate the cost of prescription drugs, which Democrats have failed to achieve in the past.



Video: Whitmer, GOP leaders cut deal on budget talks, work rules (WZZM-TV Grand Rapids-Kalamazoo-Battle Creek)


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The effort is certain to trigger Republican opposition and potentially reopen a fierce debate among Democrats on healthcare. The last Democratic presidential primary was largely defined by policy brawls over Medicare for All and whether Americans should be able to keep their private coverage in a reform effort.


Expanding Medicare access is popular with voters, however, particularly reducing prescription drug costs. Up to now, however, Biden and Democrats have directed their efforts at expanding the insurance subsidies available under the Affordable Care Act.

Widening Medicare coverage could run into roadblocks in the Senate from centrist Democrats. Sen. Joe Manchin of West Virginia has stated his opposition, complicating the path ahead for other Democrats supportive of the measure. "No, I'm not for it, period," he told The Washington Post last month. It's unclear why Manchin opposes it, although he told The Hill in 2019 the government "can't even pay for Medicare for some."

Biden continues negotiating with Republicans on an infrastructure plan, and the talks are set to stretch into at least early June. The White House did not include a Medicare expansion or a blueprint to cut the price of prescription drugs in its economic plans, though it called on Congress to approve the measures in its budget without laying out specific policies.