The U.S. is wrestling with a massive mental health crisis – impacting young people in particular. Half of young adults and one-third of all adults report that they always feel anxious or have often felt anxiety in the past year. One-third of respondents could not get the mental health services they needed. Why? 80% say they couldn’t afford the cost and more than 60% said that shame and stigma kept them away. The shortage of mental health providers also means that care can be very hard to find, even when we try hard to find it. Usually on the Medicare for All Podcast, we focus on the stories we think you need to know about. Today we decided to scrap the show and come up with a plan to get an hour of free therapy!^*

(^*Not really. None of this information is intended as medical advice.)

Our guests today are Dr. Pamela Fullerton and Lindsay Baish. 

Lindsay is a therapist and an Licensed Professional Counselor (LPC) in Illinois and a certified trauma professional – and former volunteer for the podcast.

econsulting.com/">Dr. Pamela Fullerton, Ph.D., is the founder and clinical director of Advocacy & Education Consulting, a counseling and consulting organization dedicated to ensuring social justice and advocacy through equitable access to mental health and well-being services. She is a Latina bilingual Certified Clinical Trauma Professional (CCTP), a Certified Dialectical Behavior Therapy professional (C-DBT), a Certified Clinical Anxiety Treatment Professional (CCATP), a Certified Grief Informed Professional (CGP), and a clinical supervisor and consultant specializing in working with BIPOC communities, undocumented communities, immigration and acculturation, trauma, anxiety, life transitions, and career counseling. In addition to being a professional writer and speaker, Dr. Fullerton is an adjunct instructor in the Counselor Education department at Northeastern Illinois University. She is also a volunteer contributing writer for three publications and runs a nonprofit to support Latinx youth in the Chicagoland area. Dr. Fullerton consults for two behavioral health advisory boards, Sinai Urban Health Institute (SUHI) and Illinois Unidos/Latino Policy Forum, providing advice and input to assist in promoting health equity and justice initiatives for underserved communities in Illinois.  

Show Notes

Pam tells us that counselling is a subset of psychiatry and psychology that started as a movement for career development for veterans returning from war. The profession started helping people through life transitions puts people and their lives and livelihoods at the center.

Lindsay notes that a lot of the language of mental healthcare is used interchangeably, but there are distinctions: psychologists have PhDs and can provide therapists; psychiatrists have MDs and can prescribe medications. Counselors and therapists can diagnose but not prescribe.

Congress passed the Mental Health Parity and Addiction Equity Act in 2008 to prevent insurers from providing worse coverage for mental health than they do for medical or surgical treatment. However, mental health providers are not usually treated the same as medical doctors when it comes to insurance coverage and payments.

Historically, counselors are the newest mental health clinicians on the scene and are more limited by insurers than more established clinicians like social workers or psychologists. Insurers often only reimburse for certain therapeutic models of care (Cognitive Behavioral Therapy, for example) leaving other kinds of counseling uncovered in the midst of a crisis in mental healthcare.

Pam tells us that a big part of her job is the extra work to navigate her patients’ insurance plans, Medicare and Medicaid in order to get coverage for their care. Most Americans can’t afford to pay out of pocket for mental healthcare. Counselors just got approved for Medicare reimbursement on January 1, 2024, but Pam tells us her first application was denied, as was Lindsay’s supervisor’s. Couples and family counselors were just approved for Medicare as well.

Lindsay notes that no two insurance companies pay out the same rates, so some plans are not worth taking because the payout will be late, small, and requires hours of red tape to receive. Ben calls this “rationing by inconvenience.”

Illustrating the troubling priorities of the healthcare industry related to mental health, Lindsay shares a story about the Diagnostic and Statistical Manual (DSM), the encyclopedia of mental health diagnoses. The DSM is put together by the American Psychological Association, where panels of providers create and refine criteria and definitions for diagnoses. Those panelists are required to disclose who they have received funding from including pharmaceutical companies and insurance companies. A recent study found $14 million in undisclosed industry payments to some of those panelists, representing countless conflicts of interest.

Americans have responded in a lot of different ways to the difficulty of getting mental healthcare including millions who go to TikTok for mental health advice. On the bright side, many of us have found out we aren’t alone helping to reduce the stigma of talking about mental health. Unfortunately social media has also disseminated misinformation leading to mistaken self-diagnoses. Lindsay is actually on TikTok, talking about her specialty areas and social liberation issues in psychology, because it provides a space for some people who don’t feel welcome in the traditional healthcare setting.

Since COVID, we’ve seen the rapid growth of virtual mental health services. This feels a bit like the Uber-ization or Airbnb-ification of mental health services. In theory these platforms are great for access, but many are poorly regulated and the therapists are often not held to professional standards. The FTC found that one platform, Better Help, sold patients’ data.

One of the things we always say about Medicare for All is that it would take the business out of healthcare. What would it look like if we took the business out of mental healthcare? Currently most Americans’ insurance is tied to employment, and that plan can change due to their employer’s bottom line. There’s something particularly insidious about developing a trusting therapeutic relationship with a mental health professional only to lose coverage and having to start over finding another provider who will accept the new plan. Pam dreams of a healthcare system divorced from profit, where we can do more preventative mental healthcare and collective healing, and not wait until someone is in crisis.

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Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform! This show is a project of the Healthcare NOW Education Fund! If you want to support our work, you can donate at our website,now.org/donate-hcnef/"> healthcare-now.org.

We hear it over and over again – the private sector just does it better. Whether we’re talking education or healthcare or our criminal justice system, the default Republican (and sometimes Democratic) talking point is that competition in the marketplace allows the best ideas and best people (Elon Musk, lookin at you) to rise to the top and lead us to a utopian future (sponsored by Meta).

But then something wild happens like the cyberattack on UnitedHealthcare, which is causing massive fallout throughout our healthcare system over the past two weeks – so much so, that the company appears to have paid a 22 million dollar ransom to the hackers who breached their system and now the federal department of Health and Human Services has had to bail them out. That kind of thing really makes you question how anyone is still making the argument that the private sector has this shit handled. This episode, we’re bringing in special guest and political messaging expert Jordan Berg Powers to talk about how we talk about all of this stuff: public healthcare, private corporations, and how to message our way out of the corporate hellscape in which we currently find ourselves!

Jordan Berg Powers is a consultant and the former director of Mass Alliance. Most importantly, he is coming up on 30 YEARS of experience in campaigning and organizing for progressive causes and candidates. Jordan is a return guest to the podcast, first appearing in our My Big Fat American Healthcare episode.

Show Notes

UnitedHealthcare debacle is a little bit fun for us because we get to talk about the failures of a really shitty company, but like any healthcare debacle, there are some serious consequences. What happened here, and what does the UnitedHealth scandal look like for folks on the ground?

Starting on February 21, a group of hackers breached “Change Healthcare,” which is the largest electronic medical records and medical claims processing platform in the country. About half of all Americans’ health insurance claims pass through Change Healthcare, which was bought two years ago by UnitedHealthcare, the largest health insurer in the country.

Following the hack, Change Healthcare shut down its entire network, leading to complete mayhem in the healthcare system, which is still ongoing:

• “Hospitals have been unable to check insurance benefits of in-patient stays, handle the prior authorizations needed for patient procedures and surgeries or process billing that pays for medical services. Pharmacies have struggled to determine how much to charge patients for prescriptions without access to their health insurance records, forcing some to pay for costly medications out of pocket with cash, with others unable to afford the costs.” (healthcare-outage-drags-fears-100028869.html">source)
• This has led to a financial crisis for many hospitals, health clinics, physicians, and pharmacies, none of whom can be reimbursed for the care they’re providing, since they can’t submit medical claims. Provider associations are losing their shit, and the federal government has had to intervene to try to bail providers out in the meantime. 
• The story keeps getting crazier and juicier: apparently UnitedHealthcare made a ransom payment of $22 million to the hackers who breached their system using BitCoin (source) – p.s. those are our healthcare premium dollars hard at work
• Russian hackers may now have access to almost half the country’s medical records. I’m sure that won’t come back to haunt anyone in the years to come!

As much as we’d love to dwell on the UnitedHealthcare scandal that is unfolding, this incident really got us thinking about the broader debate over distrust of government, hatred of taxes, and bipartisan worship of market-based solutions.

Jordan explains the false dichotomy of government vs marketplace, public vs private; there is no marketplace without government. The question is, which way does the government tilt the marketplace playing field? The debate about government vs private market run healthcare isn’t productive. We should be concerned about the fact that we’re all being robbed to make rich people richer. UnitedHealthcare is owning so much of the healthcare marketplace is the result of 40 years of Wall Street profiteering at the expense of American patients and the security of our data.

Over the last 40 years the Right has been very successful at convincing Americans that the government is bad at everything. One slogan or one campaign can’t undo that. The message that does cross party lines is that we’re being ripped off.

The reason we need public programs like public education and healthcare is because they give the people oversight. Not only do they provide opportunities to the marginalized in our society, they are the only thing we can control.

It often feels like those of us who are fighting for the expansion of the public sector through programs like Medicare for All are constantly fighting the notion that government is dangerous, in part because the private insurance industry has controlled the national narrative about healthcare.

A weakness of the Left is letting the opposition frame the debate, and then trying to win the argument on their terrain. Jordan drops the truth bomb we all need to hear: you’ll always lose when you argue in good faith against bad actors. We have to control this impulse, and instead talk about our own good ideas not their dumb ones.

Another mistake we make is to fight an intellectual fight, when the Right is fighting about emotions. We need to work in the emotional state: this system is stupid, they’re stealing from us. We have to tell that story.

Ben reminds us of a report called “Parroting the Right” by Partners for Dignity and Rights, fka NESRI, which found that the health insurance industry got the entire media and polling landscape to use their framing when discussing universal healthcare. You won’t see terms like corporate-run healthcare or public insurance in polls about Medicare for All; you’ll see questions about government-run vs. private healthcare. now.org/medicare-for-all-polling/">It’s actually pretty remarkable with this biased polling language how many people still support Medicare for All.

Inside Medicare for All world we spend a lot of time talking about finding just the right words to articulate our cause. We love to talk about talking, but what we love even more is to fight about talking. One really good example is the internal movement debate about whether or not we should talk about healthcare in terms of human rights. A few years ago, Vermont nearly won single payer using rights based language. On the other side of the coin, now.org/wp-content/uploads/2024/03/Matt-MacWilliams-Crafting-Our-Message.pptx">messaging research in Minnesota found that voters had poor responses to rights-based language.

Rather than fighting about how we describe our solution, Jordan thinks that we need to get away from leading with solutions entirely; we need to take voters on the emotional journey first, before we bring them to the solution. We should start by talking about the broken system and lead people through their emotions of outrage. We need to be outside of for-profit hospital HQs and insurance giants, protesting that they’re stealing from us.

Instead of fighting about messaging and policy, what our movement needs most is people to have conversations with each other about how terrible healthcare corporations are. As fun as it is to fight amongst the choir, we need to talk to people and build the outrage. We don’t need more people who don’t know what they’re doing arguing about messaging and tactics; we need more people to talk to people, or pay someone to talk to people, says Jordan with the next great Healthcare-NOW t-shirt slogan.

Have you donated to Healthcare-NOW recently, by the way?

TL;DR: the #1 organizer question is “tell me how awful your life is.” Works in any setting, with any person: another patient in a clinic waiting room, a harried doctor or nurse, or an unorganized worker. The real “messaging” we need to worry about is the conversations we have with individuals. Instead of arguing about a hypothetical ad buy we can’t afford and won’t move the scales, work on the conversations!

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Occasional fistfights aside, most of our legislators make the choice to use their words when they’re angry, and a lot of those words go into public letters they write to presidents, officials, and even each other. Despite the fact that no one else in this country has written or read a letter in decades, the public comment letter is still popular with politicians, who have elevated this obscure literary genre to a competitive sport, using these letters to demonstrate their power, build alliances, and shape policy. Today we’re going to focus on one ongoing battle of letters over one of our favorite topics: the privatization of Medicare through a program known as Medicare Advantage. We’ll talk about how all the players in the debate about Medicare Advantage are engaging in that battle, and how it could impact our access to healthcare!

Show Notes

now.org/?s=medicare+advantage">We’ve recorded a bunch of episodes about Medicare Advantage!

Medicare Advantage was created as a private, for-profit alternative to traditional (or public) Medicare, was the promise of lower costs… which never happened. Surprise: Medicare Advantage plans are FAR more expensive to taxpayers than traditional Medicare for covering the same person, costing taxpayers $7 billion more per year than if everyone were just covered by traditional Medicare. (source)

It’s the healthcare Joe Namath, Jimmy JJ Walker, and Big Papi are selling to seniors with big promises of coverage for vision and dental care, transportation, groceries, and more – for $0 premiums. Free shit!

Private companies drain public money to provide generally substandard insurance. These companies are exploiting a legit problem in Medicare, where many seniors are forced to pay premiums for medigap plans to cover stuff like chewing and seeing.

If you can’t afford the premiums for Medigap coverage, but you need to chew or see, you might be forced into an Medicare Advantage plan just because that’s what you can afford month-to-month. And that could be fine… until you need care and find out that the copays and deductibles are too high, there are super limited networks, or the insurance company refuses to pre-authorize your treatment.

But many of these MA plans don’t come through on their wild promises, and in fact, seniors end up being pushed out of MA and back into original Medicare when they are sick and actually need care. Private insurance companies love collecting money,but they hate paying money for the service they’re supposed to provide. Go figure! 

We put out a report about this! now.org/medicare-advantage/">Taking Advantage

Who’s Who?

AHIP: “America’s Health Insurance Providers” is the trade organization for the health insurance industry. Unsurprisingly, they are big proponents of Medicare Advantage.

AHIP has written their own comment letters to CMS (the Center for Medicare and Medicaid Services) advocating for expansions to the MA program since at least 2015. Lately they also began coordinating their besties in the House and the Senate to write letters on their behalf. They claim that Medicare Advantage will expand the program to more seniors, and present some of their own research:

• MA will bring more money into the Medicare system… because MA plan holders use less care. (nothing to brag about!)
• MA is production.s3.amazonaws.com/documents/202312-AHIP_MA-Demographics-Report-v05.pdf">serving a diverse populatio
  • “As of 2021, approximately 59% of Hispanic or Latino/a individuals and 57% of Black individuals eligible for Medicare choose Medicare Advantage plans. Overall, 54% of Medicare beneficiaries who belong to diverse populations choose Medicare Advantage.”
  • Turns out if you set out to exploit a diverse demographic of people, you can!

In 2021, 70 members of congress signed “dear colleague” letter, initated by initiated by Reps. Val Demings (D-FL), Mike Gallagher (R-WI), Marc Veasey (D-TX), and Gus Bilirakis (R-FL). 

In production.s3.amazonaws.com/documents/23.01.30_Senate-Bipartisan-Medicare-Advantage-Letter-1.pdf">2023 – 60 Senate signers – a good example of how this is insidiously bipartisan, John Fetterman signed right next to Ted Cruz

In 2024 – 60 Senators, but only 16 reps signed on to their version. That’s because of the OTHER letter, which Congresswoman Pramila Jayapal has been whipping up support for in the house.

The Good Guys

Organized resistance to Medicare Advantage is actually fairly new (last few years)! Just a couple of weeks ago a COUNTER letter was to Biden and the agencies that run Medicare calling for major reforms to Medicare Advantage and essentially pointing out that it sucks. The letter was led by three Reps – Jayapal, DeLauro, Schakowski – was ALSO signed by 70 Representatives, so suck on that AHIP! (P.S. there are 435 voting members of Congress, so most of Congress is taking the cowardly fence-sitting approach to Medicare Advantage) (MA-Letter-Final-with-Signatures3.pdf">source)

The letter makes four demands, one of which is already kinda sorta happening:

1. Ban Medicare Advantage plans from creating prior authorization barriers that can’t be used in traditional Medicare, such as “step therapy.” (Banned by Obama, un-banned by Trump, and… allowed under Biden. Grrr.)
2. Require Medicare Advantage plans to include all providers in their networks that are included in the public Medicare plan. One trick MA uses is to have extreme limited networks, so you might not be able to get certain types of care at all in your area.
3. Stop overpaying Medicare Advantage by preventing “upcoding” and paying them the accurate amount for the patients they cover
4. Finally, use all the savings to expand Medicare coverage for everyone: we could cover dental, vision, and hearing with money leftover; or we could reduce or eliminate the premiums and deductibles that Medicare enrollees still have to pay.

This last bit is particularly important, since it’s problematic to just end the MA program – this would require many low-income people to spend more to buy Medigap plans. They’d have much better coverage, but many can’t afford that better coverage. 

There will be a separate Senate letter, but we don’t have details yet. (There’s still time to ask your Senator to sign on.)

What does the Other Letter mean? It’s a show of power in a legislature where it’s difficult to put progressive policy up for a vote and actual voting ends in gridlock. Based on the numbers, we can see the tides turning on Medicare Advantage.

Remember that even though these letters are important for signaling shifts in the balance of power, the real organizing happens at the grassroots level, not on Capitol Hill.

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This show is a project of the now.org/donate-hcnef/">Healthcare NOW Education Fund! If you want to support our work, you can donate at our website, now.org/">healthcare-now.org.

Resources

Jayapal Press release: https://jayapal.house.gov/2023/02/16/jayapal-delauro-schakowsky-lead-effort-to-reform-medicare-advantage/

Jayapal Full letter and signers: MA-Letter-Final-with-Signatures3.pdf">https://jayapal.house.gov/wp-content/uploads/2023/02/230216-MA-Letter-Final-with-Signatures3.pdf

AHIP press releases:

https://www.ahip.org/news/press-releases

Here at the Medicare for All Podcast, we love calling out all the bad actors in our healthcare system – greedy insurance companies, soul-less CEOs in Big Pharma,profit-hungry “non-profit hospitals”, and all our favorite villains. Mostly, we look at the ways those predators target sick people and poor people for exploitation, but today we’re looking at what happens when they start fighting each other for a bigger piece of the pie? Specifically, we’re going to explore the world of hospital consolidation – that’s when smaller hospitals merge to form bigger corporate entities who can battle it out with insurance companies to secure more of patients’ healthcare dollars! What does hospital consolidation mean for regular people? No spoilers, but it turns out that when giant healthcare monsters go at each other, much like when Godzilla took on Mothra, it’s the rest of us tiny humans who suffer!

Show Notes

Like every major industry in this country, healthcare is full of big corporations that will stop at nothing to get bigger, using the time-honored capitalist techniques of mergers and acquisitions to become HUGE corporations. But, of course, we live in America, where bigger is always better – what could possibly be wrong with bigger, better healthcare companies?

We start out this episode with a cautionary tale from Massachusetts that began in 1994, when two of Boston’s biggest hospitals merge to create a mega-corporation called “Partners Health,” which over the next two decades bought up… everything. This was a response to a national wave of insurance company mergers and consolidations, which allowed insurers to squeeze both patients and providers under “managed care.” Hospitals, not wanting to be out-squeezed, fought back with their own mergers, ostensibly so they could negotiate with insurance companies.

Of course, what actually happened was something much more nefarious – and secretive. In fact, we only know any of this happened thanks to the Boston Globe’s illustrious Spotlight reporting team, who dug up the truth in a 2008 article.

Basically, in 2000, Dr. Samuel O. Thier, chief executive of Partners HealthCare, and William C. Van Faasen, chief executive of Blue Cross Blue Shield of Massachusetts engaged in an unwritten agreement between the two entities without putting it in writing to avoid legal implications. The agreement involved Blue Cross Blue Shield giving significant payment increases to Partners’ doctors and hospitals, and in return, Partners would protect Blue Cross from allowing other insurers to pay less, effectively raising insurance prices statewide. This “market covenant” marked the beginning of a period of rapid escalation in Massachusetts insurance prices, leading to a significant annual rise in individual insurance premiums.

Partners used its clout to negotiate rate increases, pressuring other insurers to match or exceed the payment increases given by Blue Cross, leading to cost increases for consumers. In turn, Partners’ significant growth and influence in the healthcare industry compounded the impact of this backroom deal, leading to a substantial rise in medical costs in Massachusetts.

Partners employed aggressive tactics, resulting in major payment increases benefiting a few powerful hospital companies while leaving others behind. This led to significant payment disparities, with Partners’ flagship hospitals earning substantially more than other academic medical centers.

Partners is an outstanding example of the evils of hospital consolidation, but it’s not an anomaly. This episode was originally inspired by our friends at the Minnesota Nurses Association (shout out to Geri Katz), who last year were fighting a proposed merger of Fairview Health with Sanford Health, two giant corporations with dozens of hospitals and clinics.

Fortunately, the nurses and MN patients won this fight – merger talks were abandoned – but consolidation across the healthcare system in the United States has run rampant the past decade, with every possible healthcare corporation merging with every other possible healthcare corporation: hospitals buying other hospitals, for-profit private equity firms buying up anything they can flip for a short-term profit, insurance companies buying hospitals, retail pharmacy chains buying the pharmacy benefit management companies that exist only to negotiate with retail pharmacies. It has become almost impossible for free-standing, independent physicians to practice on their own, just as it’s become almost impossible for freestanding, independent community hospitals to survive. Whether you’re seeking care at a hospital, a physician’s office, a dialysis clinic, or a nursing home, the landscape facing patients is a shrinking number of mega-healthcare-corporations.

What are the consequences?

Generally, patients have fewer options for medical care. Between 1998 and 2021, the American Hospital Association reported 1,887 hospital mergers. By 2017, in most markets, a single hospital system had more than a 50-percent market share of hospital discharges.

Now all this negative talk about mergers might make us sound a little bit like old-school capitalists advocating for greater “competition” in the healthcare “marketplace” – but you know us better than that! Decades of for-profit healthcare in this country have demonstrated that market competition isn’t much better for patients than healthcare monopolies – it does nothing to decrease costs or improve care.

At Healthcare NOW, we’ll keep fighting to get the market out of our healthcare system altogether so we can stop talking about corporate nonsense like vertical integration and get back to focusing on health and human dignity!

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Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform! This show is a project of the Healthcare NOW Education Fund! If you want to support our work, you can donate at our website,now.org/donate-hcnef/"> healthcare-now.org.

Just this Monday, we celebrated Martin Luther King Day, a tribute to one of the great leaders of the movement for racial justice – but something that often gets forgotten in the flurry of MLK quotes that become memes this time of year is that equity in healthcare was a crucial part of King’s vision. Throughout his career in activism, he often stated his conviction that “Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman.” Sadly, over 50 years after his death, racial inequity in healthcare is even more shocking and inhuman. Today, we’re joined by public health expert Walter Tsou to do a deep dive into the horrifying world of racial health injustice, how we got here, and how we make real change.

Show Notes

The show is joined on MLK Day by Dr. Walter Tsou – past president of the American Public Health Association and former health commissioner of Philadelphia! Gillian asks how Walter dedicated his life to health access and health equity. When Walter graduated from med school he stumbled into a job at a public health clinic in West Philadelphia that treated patients lacking private insurance or the money to afford medications, which gave him his first window into the deep economic, racial, and health divides in the U.S. This launched his career in public health advocacy.

Walter served as the Health Commissioner of Philadelphia from 2000 – 2002, and to him the most stark racial inequity he had to deal with was the gap in infant mortality – black infants at that time were 2.5 to 3 times as likely to die before reaching age 1 than white infants. Walter looked up the most recent statistics in preparation for the podcast, and the number had barely changed. The traditional way that states are pretending to do something about infant mortality is to create an Office of Equity contained inside their Department of Health that has maybe two staff people. To make a real difference in infant mortality, Walter says, you have to tackle the largest social determinants of health – education, job opportunities, housing, transportation, and so on. Two or four people in an Equity Office aren’t going to make a difference – it’s window dressing.

On top of this, Walter says, the U.S. has abandoned most of its community health work, which was widespread under LBJ’s Great Society programs after WWII, when community nurses would go into communities and address social determinants of health.

Gillian backs up to share some of the big-picture distressing findings from the Commonwealth Fund’s scorecard on racial equity in U.S. healthcare:

• Provisional life expectancy report released by the CDC in 2020 shows that Black and American Indian/Alaskan Native people live fewer years on average than white people (508.pdf">see data here)
• Black/AIAN individuals more susceptible to chronic diseases like diabetes, hypertension
• Higher rate of pregnancy related complications, higher infant mortality rate (see now.org/blog/billed-at-birth-maternal-healthcare/">our episode on maternal health for more details)
• Poor healthcare outcomes are driven by higher poverty rates, higher-risk environments, less access to healthcare among communities of color
  • Less likely to have health insurance, more likely to incur medical debt, more cost-related barriers to care, less preventative care
• These unequal health outcomes persist across all states in the U.S.
• Black women are more likely to be diagnosed with breast cancer at later stages and to die from breast cancer than white women
• Uninsured rates are much higher in communities of color, particularly states that have not adopted Medicare expansion
• Black Medicare beneficiaries are more likely than white beneficiaries to be admitted to a hospital or to seek care in an emergency department for conditions typically manageable through good primary care
• Lower rates of vaccination – example – Black, AIAN, and Latinx/Hispanic adults are less likely than AANHPI and white adults to receive an annual flu shot

Walter highlights that the history of racism in U.S. healthcare, including the infamous Tuskegee syphilis experiment on black men, meant that when COVID struck, communities of color generally had less trust in the medical system and the opinions of medical experts, in addition to being more impacted by social determinants of health.

How would Medicare for All impact racial inequities in healthcare? It would be a huge step towards leveling the playing field, but it’s not a solution by itself – there is a huge concerted effort needed to guarantee equal access to health services, and M4A would also not in itself address social determinants of health (education, housing, environment, etc) that have such a profound impact on whether we get sick or injured in the first place. Ben points out that our current healthcare system is linked to the job market, where most people get their health insurance, and if you don’t get healthcare through your job then it’s linked to your access to money, to purchase insurance on your own. This means that any racism in the job market has an impact on your healthcare coverage, and any racism in access to money and financial security also impacts your healthcare coverage. Medicare for All would at the very least de-link your health coverage from these other systems, which are deeply marked by racial inequities.

Walter closes by talking about how the tide within the physician community is turning towards support for Medicare for All, as doctors face more and more barriers to treating patients. A younger generation of doctors is leading the charge within the American Medical Association and state medical associations.

Credits

Our podcast manager is Angelique Davis, our researcher for this episode was Sophia Simeone, and our audio editor was Christian Brandt!

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Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform!

This show is a project of the Healthcare-NOW Education Fund! If you want to support our work, you can donate at our website, healthcare-now.org. It’s end-of-year giving season, and thanks to a generous matching gift from the United Steelworkers Union, every dollar you give will be doubled, so please make your way to our website and chip in!

2023! What a year! Overall, it probably wasn’t the worst year ever: On the positive side, we had Barbenheimer, the Titan Submarine implosion, congressional hearings on UFOs, and all the Taylor Swift gossip you can handle. On the negative side, we had long Covid; the deaths of Matthew Perry, Andre Braugher, and Twitter; war in Gaza , war in Ukraine, and Kanye West is an antisemite now. So yeah… overall it was pretty bad. But what about the very specialized world of American healthcare? How did everyday folks fair when it came to getting the care they needed? In this episode, we’re breaking down the highs and lows of healthcare in 2023, from Mifipristone access to Medicaid unwinding and everything in between!

Reflecting back on 2023 in healthcare, Ben & Gillian wrote up some Naughty & Nice lists! They start with the Naughty, since it’s better to end on the victories for all of our mental health going into the holidays.

The Naughty List

Starting big picture, Ben pulls out some of the basic data from the Commonwealth Fund’s 2023 Health Care Affordability Survey, which captured the state of access to healthcare in the middle of this year. The big takeaway – our access to care is getting dramatically worse, not only because the healthcare system is getting more expensive, but because inflation has been squeezing everyone’s ability to afford those big cost barriers. Top-lines from the survey:

• “Half of working-age adults said it was very or somewhat difficult to afford their health care costs.“
• Why? “Nearly two-thirds of working-age adults said that price inflation in the past year affected their family’s ability to afford health care.”
• “Nearly two of five working-age adults reported delaying or skipping needed health care or a prescription drug in the past year because they couldn’t afford it.”

Gillian added some staggering findings from the survey relating to medical debt and people avoiding care due to costs:

• “Nearly one-third of working-age adults reported having medical or dental debt they were paying off over time.“
• 22% of people with medical debt had $5k or more
• The toll this took on our health outcomes? “More than half of working-age adults who said they delayed or skipped care because of costs said a health problem got worse as a result.“

Also on the Naughty list for 2023, Gillian adds the devastating “unwinding” of Medicaid, which kicked 9 million people off of their Medicaid coverage, most of whom are qualified for Medicaid but were churned out due to administrative barriers or errors. Of those 9 million, Gillian’s home state of Texas alone is responsible for kicking 1.7 million residents off of Medicaid.

The Medicare for All podcast has covered several dangerous/naughty trends in 2023, including the right-wing now.org/blog/transgender-healthcare-under-attack/">attacks on gender-affirming care in many states, and obviously the attacks on reproductive health in the wake of the Supreme Court overturning Roe v. Wade.

Gillian adds to the Naughty list Donald Trump’s recent attempt to resurrect efforts to “repeal and replace” the Affordable Care Act, despite having completely failed at the effort in his first year as President in 2017.

And lastly, Ben wants to add to the Sad List (moreso than the Naughty List) the looming departure of Stephanie Nakajima, former Director of Communications for Healthcare-NOW and former co-host of this podcast, who will be moving to Denmark with her husband at the end of the year. Stephanie worked at Healthcare-NOW for 6 years before serving as the Executive Director of Mass-Care, the Massachusetts Medicare for All grassroots organization. We love you Stephanie and will miss you!

The Nice List

What were some of the things that really went right in 2023, from an organizing and a policy perspective?

• Gillian starts with the introduction of the two Medicare for All bills in Congress this year: both bills added explicit language that guarantees access to abortion and all other reproductive health services for all Americans, and also added explicit language making access to gender-affirming care a right. These are language changes Healthcare-NOW has been fighting for for over decade now!
• The bills were also introduced with the same number of co-sponsors as last session, which was an incredible organizing accomplishment given the loss of Democrats in both the House and the Senate (including many, many former co-sponsors).
• Ben notes that the M4A movement also made major inroads this year pushing back against the privatization of Medicare. Every session the health insurance industry lobby (AHIP) circulates a letter calling for unfettered support and expansion of Medicare Advantage plans, which is signed by many Republicans and Democrats. In response to grassroots pressure, this year the Senate letter saw a decline in signers as several Democrats dropped their support, and the House letter lost so much support that AHIP declined to release it at all.
• In 2023 Healthcare-NOW launched its now.org/voices-of-us-healthcare/">“Voices of U.S. Healthcare” project, which we’re incredibly excited about and is designed to capture the stories of thousands of American residents who have been impacted by our broken healthcare system. now.org/tell-us-your-healthcare-story/">Share your story with us if you haven’t already!

It’s that time again folks… time for a Mailbag Episode! We reached out to our whole audience and all our supporters to find the pressing questions on everyone’s mind. Or at least we would have if Gillian hadn’t been too busy eating turkey to email our list. So instead, Gillian reached out personally to some of our superfans (anyone in her contact list who had previously admitted to listening to the show once) to find out what they wanted to hear from us. And here we are, with questions about everything from Ronald Reagan to elder care to dinner table conversation from some of our favorite stans!  

Show Notes

Question from Liam Meyer in Massachusetts:

“Maybe discuss this on your podcast: term-care-facilities-costs.html">Facing Financial Ruin as Costs Soar for Elder Care – The New York Times.”

“You could also talk about elder care and how wildly fucked up it is. One especially galling bit is how Medicaid is basically built to just ignore cognitive stuff. Almost all metrics are about physical health so, like, if someone’s grandpa **could** theoretically cook and shower themselves (ie, “He can stand up and walk, he still has hands!”), Medicaid says it all good even if grandpa doesn’t know where the shower is, leaves the stove on all the time, and continually eats spoiled food.”

Answer: “elder care” is a vague term that mooshes together lots of kinds of care for seniors. But “long-term care” is better defined, and has been a major focus of ours in recent years, needed not only by older folks but anyone with a physical or mental disability that means they need help with day-to-day living. Most of us will need long term care at some point in our lives.

What’s wrong with the U.S. long-term care system?

• We don’t have one! 
• Very few people are insured for long term care
• Medicaid covers the vast majority of long term care services – you have to be or become poor to qualify (except in Limit-Changes-for-Non-MAGI-Medi-Cal.aspx#:~:text=Phase%20I%20was%20implemented%20on,member%20(up%20to%2010).">California, where Medicaid asset limits will be eliminated starting January 1, 2024!) We’ve heard many stories of people who have had to sell homes or farms, affecting their whole family, in order to become eligible for Medicaid.
• Institutional bias: Medicaid will pay for long term care in a setting like a nursing home, but not home-based care which is cheaper and better for quality of life.

Check now.org/blog/the-longterm-care-crisis-in-the-united-states/">our our long term care episode for much more.

Questions from Geri Katz in Minnesota:

“Have you listened to the 1961 Ronald Reagan Speaks Out About Socialized Medicine LP? Why has the AMA historically opposed single payer?”

Answer: in 1961, before Medicare passed and before he was elected Governor of California, Reagan was a washed up actor talking about how “socialized medicine” would ruin our country. He sounds like a ghoul: “One of the traditional methods of imposing statism or socialism on a people has been by way of medicine. It’s very easy to disguise a medical program as a humanitarian project. Most people are a little reluctant to oppose anything that suggests medical care for people who possibly can’t afford it.”

Reagan was paid by the American Medical Association (AMA) to deliver this speech, which was printed on an LP so you could host a house party with your socialism-hating friends. The AMA has a long history of opposing healthcare reform, such as:

• In 1948 when Truman proposed a national healthcare program – which was supported by an estimated ⅔ of americans – the AMA decried it as socialism and used member dues to fund a political campaign against Truman’s plan.
• After passage of Civil Rights Act in 1964, the AMA continued to allow medical societies to discriminate against physicians of color.
• The AMA has been involved in campaigns against Social Security, Medicare and Medicaid.
• The AMA is a scam! According to Dr Linda Girgis, “Perhaps the biggest example of how doctors lost their trust in the AMA is the way they are funded. With less than 20% of US doctors paying membership dues, it is apparent they secure funding from other sources. One of their biggest streams or revenue is their profits from selling billing coding, insurance, and other products. Most doctors disagree with the CPT-10 billing transformation. Yet, the AMA continues to profit hugely from selling these products despite our protests. Clearly, doctors’ opinions have been shoved under foot in their quest to drive profits.”
• The AMA only represents about 15% of physicians.

There’s some exciting organizing within the AMA to rescind the organization’s opposition to national healthcare. The membership is split but the student wing, the AMSA, recently passed a resolution calling on the AMA not to oppose single payer.

Question: “Do hospital mergers and acquisitions ever work out for the community? Could M4A put the breaks on healthcare consolidation?”

We started going down a rabbit hole on this one, so we’ll do a whole episode on this in 2024!

Question: in your opinion, who is the most evil healthcare profiteer of 2023?

• Ben’s initial answer was UnitedHealth, which is being sued for using artificial intelligence to automatically deny claims, but the truth is that most insurance companies are doing that. Let’s call the AI industry the villain of the year.
• Gillian is most pissed off at Texas Governor Greg Abbott, who signed into law a ban on gender affirming care for trans youth. He’s not technically a healthcare profiteer, but he’s a political profiteer who is collecting countless political points from the far right for taking away healthcare from vulnerable children.
• Ben gives an honorable mention to PhRMA (Pharmaceutical Research & Manufacturers of America) – the umbrella lobbying organization for the pharmaceutical industry – for suing the Biden administration for trying to negotiate drug prices under Medicare.
  • They also gave $1.2 to fake grassroots groups demanding the repeal of Medicare drug price repeal.

Question From Walter Tsou: Who are your healthcare heroes and why?

Answers: Gillian’s are kramer-dead.html">Larry Kramer & the founders of Act Up, the AIDS advocacy organization that began in the 1980’s. Act Up was made up mostly by members of the LGBTQ+ community who took militant grassroots action to draw attention to the epidemic. Lots of Medicare for All activists came out of the AIDS advocacy movement.

Ben’s are Dr. Jack Geiger & the founders of the first two community health centers in the country, launched in the 1960s in Mound Bayou, Mississippi and right here in Boston, Massachusetts on Colombia Point. If you haven’t seen “Out in the Rural” – it’s a short documentary that is must-watch stuff for health justice advocates. The premise of the first community health centers was that it was ridiculous for medical providers to just treat patients’ symptoms when they showed up to a hospital or clinic, when often those symptoms were caused by poverty, by lack of work, lack of money, poor sanitation, inadequate or no housing, and structural racism. Or in the words of Geiger: “the idea that you stand around in whatever circumstances laying hands on people in the traditional medical way, waiting until they’re sick, curing them and then sending them back unchanged into an environment that overwhelmingly determines that they’re going to get sick.” So the Mississippi health center for example created a workers co-op that would allow their patients to own and run their own agricultural operations, creating jobs and income; they had a massive sanitation program installing toilets in patients’ houses and communities; they’d hand out prescriptions for food that their patients could cash in at local markets. Again in the words of Jack Geiger “We have been able to enter and to do things under the general umbrella of health that would have been much harder to do if we’d said we were here for economic development or for social change per se.”

Question: How do we overcome the fear that the crappy plans we have would be somehow better than government funded single payer?

Answer: This is the fear mongering they use whenever we get closer to passing something. But we know that no one likes their health insurers, or their insurance. We’ll need to do a lot of inoculation against this: Medicare gets rid of your insurance and replaces it with actual care. We know they’re going to lie, and we just have to be prepared to have even more one on one conversations about the truth. We’ll probably have to spend money to advertise too.

Question from Katie Worth in Texas:

“We had dinner with our cousin’s new boyfriend and he brought up that the French eat SO MUCH BETTER than Americans that they live three years longer than we do even though “we have the best medical care in the world here!” Naturally I launched into a heated lecture about how we actually don’t have the best medical care in the world except maybe for people who are extra rich, and in fact our crappy medical system is likely more to blame for our shorter lifespan than anything we eat, but his eyes glazed over immediately and he changed the subject as soon as he could. Do you have advice about how to respond to dumb bullshit in a way that won’t alienate our cousin’s new boyfriend?”

Answer:

• The French don’t live longer than the U.S. because of their food (although it’s really good food) – they live longer because they have a significantly lower infant mortality rate than we do here in the U.S. When people die before they’re one year old, that brings down overall life expectancy a lot.
• BUT ALSO: the very low life expectancy in the U.S. probably is not due primarily to our shitty healthcare system. If you want an amazing read, pick up “The Status Syndrome” by Michael Marmot, which is about the huge body of research that has shown the primary driver of life expectancy and health outcomes is our social status and our position in the social hierarchy. More equal societies have better health outcomes and longer lives. The U.S. is one of the most unequal developed countries, in addition to being virtually the only one without universal healthcare, so it’s easy to get these two things mixed up when we’re looking at outcomes.

Question from Emily Mason in Massachusetts:

“Over the holiday, my more-moderate-with-age Uncle in law took the time to explain to me that while Medicare for All is great as a concept, it doesn’t make sense with the current political infrastructure surrounding healthcare, so we should forget it as an idea. What are some good talking points to fire back with other than ‘stop thinking like a boomer?'”

“Can you please just prepare an arsenal for me to argue with my snake oil salesman of an inlaw?”

Answers:

People have always said that anything cool that disrupts the status quo isn’t feasible. But:

• Popular support for Medicare for All right now is around 69%. That’s more popular than The Civil Rights Act in 1964 (61%), Same Sex Marriage in 2015 (60%), and Medicare in 1964 (61%). Folks said those things were politically unfeasible too, but because they were popular and folks organized around these popular ideas, we won. We are many. They are few.
• We hate this the most when elected officials say this. They’re the ones who literally decide if the laws pass or not!
• Ask someone dying because they can’t afford medical treatment how feasible the current system is.

Dinner Table Notes:

• Always lead with the heart, not the stats
• Personal stories are more effective than data
• Avoid saying “I hope your family dies first”

Follow & Support the Pod!

Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform! This show is a project of the Healthcare NOW Education Fund!

This show is a project of the Healthcare-NOW Education Fund! If you want to support our work, you can donate at our website, healthcare-now.org. It’s end-of-year giving season, and thanks to a generous matching gift from the United Steelworkers Union, every dollar you give will be doubled, so please make your way to our website and chip in!

Open enrollment. Deductible. Coinsurance. HMO. Indemnity plan. If you’re listening this far, you probably have a migraine already. Understanding the language of the health insurance industry, let alone selecting a health insurance plan, can be confusing, frustrating, and disheartening. But never fear – we are here to give you a crash course on everything you need to know about your insurance plan. No need to scroll through Healthcare.gov’s Health Insurance glossary and risk throwing yourself out the window…

We want to give you some tools here to understand what you’re choosing when you pick a healthcare plan, but no one but you really knows what’s best for your health, so (for better or worse) we aren’t going to give any actual advice here about what healthcare plan to pick. 

Also, all health insurance kind of sucks, so you will probably get screwed no matter what you pick. Basically, we’re going to try to decode all the mystifying language that the insurance companies use to disguise the ways they’re going to screw you so at least you’ll be able to anticipate how you’ll get screwed.

Show Notes

Names

Whether you get health insurance offered by your employer, or you have to buy insurance on your own in an exchange or on healthcare.gov, or you have Medicare and you are looking at one of the privatized Medicare Advantage plans, you’re going to be choosing from a series of plans that have totally incomprehensible names and acronyms, so let’s start by breaking down the how the name of the plan itself will tell you something about how your insurer is going to screw you.

Generally the first part of an insurance plan’s name will be the name of the insurer (like “Blue Cross” or “United Health”), then you MIGHT get a word that says who is paying for the insurance plan (if it’s a “Group” plan that means an employer is paying for it, an “Advantage” plan is a privatized Medicare plan), and finally there will be an acronym that only 0.005% of people in America understand – and those are the generally people making money from the plans. These acronyms will be something like HMO, HSA, PPO, EPO, or my personal favorite “GTFO” – the “get the fuck out of here that can’t be a real plan” plan!

Indemnity Plans (“Open Choice” or “Open Network” plans): are the opposite of managed care; you could use any doctor or hospital, there are no networks, no review of care or pre-approvals, no claims denials. These were the plans that virtually everyone had prior to the 1980s, and plans that virtually no one has today except maybe the extremely wealthy. In 1978, 95% of people had indemnity plans, then that dropped to 71% by 1988, and by 1998 it was down to 14%. Today, only 1% of workers have indemnity plans.

Indemnity plans are the opposite of managed care – you can see any doctor or hospital you want, there Today, you probably wouldn’t even want an indemnity plan, because the modern versions usually only pay a percentage of the cost of your care, leaving you with the rest and massive bills.

Health Maintenance Organizations (HMOs) represent only 12% of insurance plans today, so after taking over in the 1990s, old school HMOs are going the way of the dinosaurs. HMOs usually limit coverage to doctors/providers who work for or contract with the HMO (“in-network”). It generally won’t cover out-of-network care except in an emergency. HMOs can also be limited by location, meaning you might have to live or work in a certain area to be eligible. 

Exclusive Provider Organizations (EPOs) are a new catch-phrase that are appearing more and more often, but they are VERY similar to an HMO, and you should think of them the same. In fact, that survey that only 12% of workers have HMO plans includes EPOs under the same category. EPOs often have larger networks than HMOs, and unlike HMOs, they don’t require referrals to see specialists – as long as the specialist is in their very limited network.

Preferred Provider Organizations (PPOs) are the dominant type of health plan in the United States today. 49% of workers are currently covered by PPO plans. Like HMOs and EPOs, PPOs have a network of providers. However, unlike HMOs and EPOs, PPOs will still cover out-of-network providers but at a higher cost, – i.e. the plan gives you a better deal and takes on more of the cost if you use providers in its network. You can see specialists and out-of-network doctors without a referral.

Point of Service (POS) is another uncommon type of plan – only 9% of workers have POS plans. The main difference with a POS plan is that they usually offer national coverage, if you’re someone who travels a lot, but if you go to an out-of-network provider anywhere in the country – big surprise coming here – you’ll be absolutely screwed with how much money you have to pay. Gillian’s dad had a spicy name for this type of insurance. 

Health insurance exchange categories

Just to make it extra confusing, plans in the exchanges are also categorized into 4 “metal categories” based on cost and quality of coverage, ranging from bronze (shittiest plan) to platinum (rich people plan). Those who buy individual insurance plan on the exchange (or marketplace) have to choose a metal level.

Bronze plans have the lowest monthly premiums, highest costs when you need care, and huge deductibles each year.

Silver plans have a “moderate” monthly premium and “moderate” costs at the point of care. Deductibles are lower than a Bronze plan. Some Silver plans come with “cost sharing reductions” or “extra savings” for some households.

Gold plans have a high monthly premium, low costs when you need care and low deductibles.

Platinum plans have the highest monthly premiums but pay the most when you need care.

What to look out for in the small print:

Summaries (or Schedule) of Benefits (SOBs) this case that isn’t a reference to the CEOS of your insurance company. In insurance lingo, SOB is is where you find the deets about what is and isn’t covered.

Premium: The amount you pay to your insurance company monthly to maintain your health insurance. Premium amounts vary along with deductibles, co-insurance, and other aspects of the plan; if other aspects of the plan are more expensive (like a high deductible) then premiums will be lower.

Deductible: The amount that you are responsible for paying out-of-pocket per year. Whenever you pay for health care services, it goes towards your total deductible for the year. After you hit your deductible, the insurance company should be covering the rest of your costs. 

HDHP with HSA (High Deductible Healthcare Plan with a Health Savings Account) A high-deductible plan can be any of the plan types listed above – EPO, PPO, HMO – provided it has a deductible of over a certain amount determined by the IRS. (As of 2023, a “high deductible” is at least $1,400 for an individual and $2,800 for a family). Insurance companies that provide high deductible plans will set up Health Savings Accounts, which allow members to set up an account where they deposit pre-tax dollars from their paycheck in order to cover medical expenses.

High deductible plans can leave you open to massive costs, depending on how high the deductible is. People with high deductibles often behave the same way as uninsured people: they delay and skip care because the cost of meeting their deductible is so high it could bankrupt them to seek care. This is also why you will find clinics andhospitals very full at the end of the year: all those people who have met their deductibles rushing to get care before their deductible reset at the first of the year.

Co-insurance: Did I say that the insurance company will pay for the rest of your costs after you hit your deductible? SIKE. A lot of the time, it won’t. On many plans, once you hit your deductible, co-insurance kicks in, meaning that the insurance company will begin covering a certain percentage, but not all, of your expenses.

Co-insurance out-of-pocket max: The maximum amount of co-insurance money that you have to pay on your plan in a given year.

Maximum prescription and out-of-pocket max: This is the total amount of co-insurance you have to pay out of pocket plus your deductible. In the biz they call this your “annual exposure.”

Co-pays: A fixed amount you pay for a doctor’s visit or a specialist’s visit. Can vary based on the type of provider or service. Can also vary based on whether or not you’ve met your deductible (they usually go down at that point)

Election tier: Plans have “tiers” depending on whether you are electing to cover yourself, yourself and a spouse, yourself and children, etc. Commonly the “tiers” would be “individual,” “Individual plus family,” “individual plus children,” “individual plus spouse”

Plan year: the “plan year” is 12 months from the date of effective coverager (when your coverage kicks in). Deductibles can either apply to a calendar year or a plan year.

COBRA: If you become ineligible for a health insurance plan that you are a dependent on (common examples would be turning 26 or getting a divorce), the payor on the plan can elect to keep you on as a dependent and pay an additional amount 

What are our takeaways here?

1. Generally, you’ll see a tradeoff in plans – lower premiums generally come with higher deductibles and more limited networks. That means that if you can only afford the lowest possible premium, you’ll get stuck with the worst coverage. So basically class warfare.
2. Again, this is all an elaborate scheme to screw you.
3. All of this is bullshit that was invented by the industry to lead you toward the choices that are worse for you and more profitable for them.
4. Medicare for All would put these fuckers out of business and make it so you never have to hear the word “coinsurance” again!

Follow & Support the Pod!

Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform! This show is a project of the Healthcare NOW Education Fund!

How much do you like this podcast? Did you learn something today? Please throw us a few bucks so we can keep providing content that helps you understand exactly how you’re getting screwed by American healthcare system! If you want to support our work, you can donate at our website,now.org/donate-hcnef/"> healthcare-now.org.

SOURCES:

The health plan categories: Bronze, Silver, Gold & Platinum | HealthCare.gov

Consumer Guide to Understanding Health Insurance | Mass.gov

Health insurance and Obamacare te rms | healthinsurance.org

HMO, PPO, and EPO – What’s the Difference and Why Does It Matter? – CalPERS PERSpective   

Managed Care: MedlinePlus

Data Resources | CMS

The Most Common Types of Health Insurance | Northwestern Mutual

Publication 969 (2022), Health Savings Accounts and Other Tax-Favored Health Plans | Internal Revenue Service   

If you’ve ever had an experience with the American healthcare system, you’ve probably walked away thinking, “Why can’t we have nice things? Or even basic human things??” We get stuck on gurneys sitting in ER hallways, waiting hours for care; we skip other basic needs like food and housing to pay for the healthcare we can’t skip; or we wait for months for preauthorizations from our health insurance and referrals from our doctors. Of course, for the super rich you don’t have to endure any of these humiliating experiences, and they have developed some new, expensive ways to get the healthcare they need when they need it. So put up your pinkies and throw on a monocle – today we’re doing a deep dive into the lifestyles of the rich and famous to find out: just how fancy is concierge healthcare, and can the rest of us get some?

Show Notes

Let’s start with concierge primary care, the latest trend in fancy healthcare! What is concierge care?

Some concierge plans (also called Direct Primary Care) work with existing insurance – those are the cheaper ones ($600-1000/year, aka Hyatt Care). Some you actually pay a flat fee that covers all your services. Those are the really expensive ones, which can run from $2400 to $30k per year!

But what do you get for your money?

• 24/7 access to doctors (some promise your physicians direct phone number)
• Coordination of care (referrals, preauthorizations if necessary)
• Extra services like a health coach!
• Some offer really crazy shit like home visits
• Physicians have fewer patients and can spend at least 30 minutes with each of them.

Now there are more than 1,500 Direct Primary Care practices across the country, and 1 in 5 of the top 1% buy concierge physician care.

We’re also seeing some hospitals, like Ben’s local mega-hospital Mass General, offering “Concierge Medicine.” They have dedicated concierge physicians who see fewer patients and are more accessible, available by phone or email 24 hours a day, seven days a week. You also get your own health coach and a dietician.

Do you need to maintain insurance? Yes. At Mass General, your $10,000 membership fee covers a high level of “service” and “access” but not the cost of the medical care you need. Your insurance plan will cover the actual services provided by the concierge physician. That means $10,000 on top of your premiums, co-pays and deductibles.

Outside of the exorbitant cost, are there downsides to concierge care? You betcha.

• It exacerbates the primary care provider shortage and creates two-tier system: direct primary care physicians have fewer patients, and also creates a two-tier system where rich people buy their way out of the physician shortage.
• Despite all the marketing claims, concierge care may not lead to better health outcomes: there is a lack of peer-reviewed studies on care outcomes in concierge practices.

But when rich people get to the hospital, don’t they get treated like the rest of us? Nope. Big hospital donors often get to skip the line in the ER and get VIP status. They get fancy luxury suites with fine gourmet dining, high thread count sheets, and suites with custom cabinetry. They also get the best nurse to patient ratios in town, with some luxury units assigning each patient their own nurse who has no other patients, 24/7.

These luxury units can be dangerous though. When the hospital is more concerned with pleasing the patient than providing the care they need, it can result in “VIP Syndrome.” There’s anecdotal evidence that because some patients want to stay in their luxury accomodations instead of being moved to a specialty or more intensive unit due to their condition, they don’t get the kind of care they need, which can lead to worse outcomes or even death. At least one study suggests that higher patient satisfaction is correlated with worse outcomes.

VIP syndrome can lead caregivers to overtreat patients with unneccesary expensive tests, or undertreat them by avoiding upsetting or painful procedures or tests. This can lead to terrible consequences. A 2016 story from the Boston Globe described a prince with “ties to Middle Eastern royalty” who was diagnosed with a drug-resistant infection, but objected to his providers wearing protective gear around him. Instead of following hospital protocols, they made an exception to make him happy, putting his and their health at risk. There was also an investigation into the amount of painkillers he was administered, and other examples of exceptions made to hospital policies to please the prince.

Another obvious downside is that this kind of VIP care is unethical to treat patients differently based on wealth or status. And treating those VIPs better takes resources away from “regular patients” who already struggle to access care and providers.

Doesn’t it seem like some of this stuff is just the kind of decent healthcare we should all have? Shouldn’t we all have access to the care we need when we need it, including providers who have time to spend with us and hear our concerns, hospitals that prioritize our comfort and treat us with respect, and the ability to get care without a health butler to handle all the complexities of referrals and prior authorizations? We at Healthcare-NOW believe we all deserve nice things, and that’s why we won’t stop pushing for Medicare for All.

Follow & Support the Pod!

Don’t forget to like this episode and subscribe to The Medicare for All Podcast on Apple Podcasts, Google Podcasts, or your favorite podcast platform! This show is a project of the Healthcare NOW Education Fund! If you want to support our work, you can donate at our website,now.org/donate-hcnef/"> healthcare-now.org.

Just over a month ago we lost Bob Barker, the man who taught us all about the brutal nature of capitalism one pricing game at a time. Now, thanks to the Inflation Reduction Act, the federal government is going to be playing a role in determining the prices for some of our favorite products. No, we’re not talking about cars or family vacations to the Bahamas – we’re talking about the prescription drugs that keep us alive! As the Biden Administration enters its own Showcase Showdown with Big Pharma, we’re taking a full episode to break down what that means and whether the result will be prices we can actually afford.

Show Notes

Our first (and only) contestant is Alex Lawson! He is the Executive Director of Social Security Works, the convening member of the Strengthen Social Security Coalition— a coalition made up of over 340 national and state organizations representing over 50 million Americans. Alex’s organization played a critical role in moving the Democratic Party (mostly!) away from efforts to cut Social Security, and has been shifting the momentum towards expanding Social Security. Social Security Works is also a key ally of ours in the national fight for Medicare for All!

Alex, come on down!

Alex starts by telling us about the time he took a camera to PhRMA’s (the Pharmaceutical Research and Manufacturers of America) office the day of the Inflation Reduction Act signing ceremony. He conducted person-on-the-street interviews, asking if they knew PhRMA spent hundreds of millions of dollars to keep Medicare from being able to negotiate drug prices, and if they had any messages for the folks in the building? Most of the responses were of the “f-you PhRMA, we got you!” variety.

PhRMA has literally never lost until the Inflation Reduction Act was passed. Even though it’s modest, Medicare went from having no authority over drug prices to the authority and mandate to find the fairest price for certain drugs is a huge loss to the industry.

Alex wants listeners to understand that this win is as simple as it sounds. Who buys the most drugs in the world? Medicare. Why doesn’t Medicare tell the pharmaceutical companies what they’re willing to pay? This is called the Maximum Fair Price. No other peer nation doesn’t have some kind of negotiated standard for drug prices.

While our guest and hosts would prefer that Medicare be allowed to negotiate the prices of all drugs used by beneficiaries, PhRMA was successful in limiting the Inflation Reduction Act drug provisions to only apply to ten pharmaceuticals. (Still, pharmaceutical companies are suing to block the implementation of price negotiations.)

Negotiating the prices for only ten drugs may seem like a drop in the bucket, but the cost of those ten drugs alone make up a huge amount of Medicare’s spending on Medicare Part D. And in coming years Medicare will be able to negotiate over ten more drugs, and so on. This will squish the most excessive profiteering of the pharmaceutical industry and deliver savings of $9 or $10 billion dollars a year.

We give President Biden credit for taking an aggressive stance against PhRMA to finally make good on an evergreen Democratic campaign promise to lower drug prices. But we also give ourselves some credit. First there was the debate in Congress in 2019 over HR3, the Lower Drug Costs Now Act. Advocacy by groups likes ours resulted in the House passing a robust bill that would have dramatically lowered drug costs. Then in 2021 both Healthcare-NOW and Social Security Works fought hard to win major expansions of Medicare in the Build Back Better bill (we were on track to win a lot more than prices for ten drugs). But Senators Joe Manchin and Kyrsten Sinema tanked the whole bill in the Senate.

Those two battles led us to the Inflation Reduction Act aiming high from the start, and resulting in a bill that will make a big impact on drug spending by Medicare. The Build Back Better fight was brutal, and we lost, but we named what we wanted: vision, hearing, and dental coverage for Medicare; long term care coverage; negotiated drug prices. We lost then, but we aimed high, so when we finally got across the finish line with the Inflation Reduction Act, we achieved a lot. It’s not everything, but it’s a remarkable start.

A few years ago Florida, under Ron DeSantis, asked for permission from the federal government to import drugs from Canada, where they are cheaper. Trump was also developing a national version of this policy to let Canada negotiate drug prices for us. They both knew the political popularity of lowering drug prices, but didn’t want to take on the pharmaceutical industry.

Drug importation policies show up at the state level, where some non-profit groups sponsor bus trips to Mexico or Canada to buy cheaper prescription drugs, and the state government of Utah actually pays for public employees’ flights to those countries because it is still cheaper than paying full price in the United States. (Your shownotes writer is reminded of an independently wealthy U.S. Senator who spent his entire Senate salary on bus trips to Canada for seniors to highlight the issue of high drug prices; that Senator went on to win two more statewide elections before retiring.)

It’s unfortunate that we continue to spend so much energy focusing on imports from Canada, whose drug prices are the second highest after the United States. As more states try to address drug prices by importing, ultimately the “solution” of importing drugs from Canada won’t be sustainable; pharmaceutical companies will eventually raise prices for Canada too. The real answer is to go to the source and negotiate prices on our own.

We’ve all heard PhRMA’s claim that if we negotiate lower drug prices, they won’t have enough money to do research and development on wonderful new life-saving drugs. Alex tells us that is completely false, and in fact, pharmaceutical corporations only “invent” rip-offs of existing drugs (“me too” drugs) using the U.S. patent system to extract maximum profit. Our current system doesn’t incentivize the companies to do R&D on drugs with the greatest public health benefit; it incentivizes looking for drugs that will deliver the greatest private gain. The real research is primarily paid for by the U.S. taxpayer, not the pharmaceutical companies.

U.S. Senator Bob Menendez (D-NJ), a “Pharma Darling,” was just indicted on federal bribery charges. Menendez is known taking loads of money from big pharma and in return almost single-handedly killing pharmaceutical price reforms like drug price negotiations. He’s hardly the only member of Congress to take funds from the pharmaceutical lobby. But over time, healthcare justice advocates have made the pharma label so toxic that some Democrats are turning down those contributions and there aren’t many Pharma Darling Dems like Menendez anymore.

We’re excited about the impact Medicare drug price negotiations will have on the power dynamics in Washington and on seniors’ wallets. This leads us to dream even bigger about the true transformation we could achieve with full Medicare for All.

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