Coping with "Medicare for all"

Good question… how can one guy do that much?

Part of how he got away with it was bribing others to participate so it wasn’t just one guy doing this it was really a network of illegal conspirators.

Different reports say he ran 20 or 30 nursing homes and assisted living facilities.

They say the fraud goes back 18 years.

Also one report said :
“Prosecutors said his healthcare network as well as other co-conspirators billed $1 billion for fraudulent medical services since 2009. In turn, Medicare paid Esformes’ skilled-nursing and assisted-living facilities and the Delgado brothers’ healthcare operations about $500 million.”

Its unclear how they get to $1.3B. Was that $1.3B he over charged people? Or $1.3B that was fraudulently paid? Above says he billed $1B and Medicare paid $500M. So maybe its only $500M? Or maybe its $500M from Medicare and $800M from other insurance and out of pocket?

But either way spreading $1B was spread across 18 years in 20-30 facilities with maybe 200 beds per facility. So we’re in the ballpark of $10k per resident treated in fraud. Or if it was really just $1B billed and $500M paid then half that.

They also said some of the fraud was unnecessary procedures and unnecessary care. They would admit patients who didn’t really need nursing home care and charge for it. Nursing home care can be 1000’s a month so if maybe 10% of the residents didn’t really need to be there across 20+ facilities then that would add up to lots of unnecessary charges very quickly.

It also says the guy in question profited $37 M from all the fraud. Thats only 3-4% of the total alleged number. I’d imagine then that most of the fraud was unnecessary care that he profited from rather than outright false charges.

I’d imagine that its easier to get away with unnecessary care than outright bogus claims. If auditors investigate then theres a patient and records of care and the argument is against a doctor who claims the care was necessary. But the doctor was bribed and complicit in the fraud.

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For guardianship there are pretty much no controls whatsoever. Anybody can be a guardian. They’re frequently appointed by judges who rubber stamp the requests due to lack of knowledge or time to process them. It’s impossibly broken and ripe for abuse.

And nursing homes are pretty much like asking the fox to guard the chicken coop. You have a captive audience of elderly people who are easily taken advantage of and you’re not spending their money (which there may be restrictions to if they have powers of attorneys) but billing Medicare for whatever you can get away with. CMS is only scratching the surface in their oversight efforts by looking mostly at staffing and not prescriptions and procedures being billed for. The fact that it took 18 yrs and $1B in fraud to catch that guy tells you all you need to know about how effective CMS is.

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here’s another $1B fraud ring busted :

The scope of this one is even larger. >100 companies 24 individual defendents and they solicited 100’s of thousands of seniors.

Bernie Sanders Unveils ‘Medicare for All’ Bill

He has support from four White House rivals for a single-payer plan to expand medical coverage.

The question is which of the Democrat candidates don’t support the takeover.

Of 14 Democratic senators who have signed on this time, four are competing with Sanders for the Democratic nod: Kamala (Kommie) Harris, Cory (Spartacus) Booker, Kirsten (two-face) Gillibrand and Elizabeth (Pocahontas) Warren.

The NY Times weighs in on the costs with their usual economic innumeracy:

In all of these estimates, patients and private insurers would spend far less, and the federal government would pay far more.
NYTimes article

Uh, let’s see. If it’s “for all” then how is “patients’ spending” different from “the government’s” spending? Oh yeah, I get it. Modern monetary theory and all that. The government will just create the money and no one will ever have to pay for it.

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Here’s how Bernie would pay for it.

50% more payroll taxes
Raise income tax rates up to 15% higher, over 50% on higher incomes
50% higher estate tax rates and tax smaller estates
Over double the capital gain tax rates
Ban employer health insurance
Plus some extra wealth taxes and odds and ends

And that’s if it comes in at or under budget, which has happened to which government project ever? But don’t worry, most of it will come from the Evil Rich.

How’s that freedom thing going? I guess it’s just one more cost of socialism.

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Sanders’ document talks about a top income tax rate of 55%

Americans for Tax Reform says 70%. But then links to a article about 70% rate proposed by Ocasio-Cortez

They seem to be conflating the differing Democrat proposals.

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Here’s Warren’s proposal for how to come up with $50T to pay for her plan.

Oops, here’s the actual and slightly less plausible real one -

https://www.wsj.com/articles/warren-to-tax-wealthy-americans-companies-to-pay-for-medicare-for-all-11572614846?mod=searchresults&page=1&pos=3

Funded with Magic Math like “better tax enforcement” that will somehow bring in 20x more than IRS estimates

She relies on collecting $2.3 trillion over a decade from tougher enforcement of tax laws. For comparison, the Congressional Budget Office estimates that boosting Internal Revenue Service enforcement staffing by 35% would raise $55 billion over a decade.

Other aspects of the plan consist of charging your employer the same amount they currently pay for your healthcare as a tax, taxing employees for the premiums they wouldn’t be paying anymore (“not a tax on the middle class”), taxing capital gains at ordinary income rates and on any capital gains including just “paper”/unrealized gains annually (don’t ask for a refund if your stock falls next year), jacking corporate taxes to 35%, and taxing any billionaire dumb enough to stay in the US 6% of their assets each year.

Sounds like drug manufacturers would go out of business, while doctors and hospitals would get rock bottom pay/reimbursements

Ms. Warren would also use compulsory licensing and public manufacturing to ensure access [to drugs]… Ms. Warren’s proposal aims to reduce administrative spending and reimburse physicians and other nonhospital providers at current Medicare rates… hospitals and physician groups have said steep cuts in payments would lead to job losses and closures.

An economist cited said the best case was such a plan would result in “chronic low growth” for the economy, and could easily trigger a recession first and not recover.

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Where does $50T come from?

Warren claims $20T, others say its more like $30T+.

It’s $30T in all the money everyone already spends (premiums, taxes, govt programs, employer paid benefits, etc), and she figures she’ll need another $20T more on top of that. From the WSJ,

Sen. Elizabeth Warren said that as president she would tap billionaires and large employers to pay the bulk of $20.5 trillion in new spending over a decade to finance her Medicare for All health-care plan

You might well ask if you’re going to pay all that extra money, and not save the money you’re already paying, maybe you ought to at least get to pick/keep your doctor, not wait 6 months for a cancer diagnosis, etc? Nah, that’s Evil Capitalist Thinking.

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OK so the +50 is the new total.

“all that extra money”

I don’t think theres extra net money. We’re talking additional government spending to replace current private spending. Its not a net +20, +30 or +50 increase.

Its more like +20-30 more federal govt. spending minus the private spending.

I"m not arguing its the best idea or worst, but I am confused by your numbers…

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As far as I can tell, this number is new federal spending. It replaces some amount of private spending. The estimate of private spending it replaces varies depending on who you trust.

Where did you get the idea that M4A would restrict your choice of doctor? As it is, the vast majority of doctors take standard Medicare (I’m not referring to Medicare Advantage), and standard Medicare enrollees can choose their own doctor. I have seen absolutely no one propose a true M4A plan that includes restricting patients’ ability to choose doctors. (I’m defining “true M4A” as a plan that builds on standard Medicare and expands its coverage without involving the private insurer parasites, not the Cigna Medicare for All-branded plan that The Onion correctly predicted some candidates – though, seemingly, not including Warren – would come up with.)

To the contrary, private insurance is what prevents, or at least substantially hinders, your ability to pick or keep your doctor. Your ability to pick your doctor in the first place is limited by your insurance network, some of which are probably on par with Medicare (e.g. BCBS national PPO) but many of which are substantially more limited than that. (Technically, your plan may allow you to go out-of-network, but typically at a significantly higher cost. I don’t consider this viable, and I don’t think most consider it viable either.) Your ability to keep your doctor is limited by the fact that insurance changes can occur – whether you get a new job with a different insurance network or your existing employer changes insurer/administrator. Under M4A, everyone is permanently covered under the same nationwide network, eliminating this volatility.

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Where did you get the idea that M4A would restrict your choice of doctor? As it is, the vast majority of doctors take standard Medicare (I’m not referring to Medicare Advantage), and standard Medicare enrollees can choose their own doctor. I have seen absolutely no one propose a true M4A plan that includes restricting patients’ ability to choose doctors.

I’m not up to date on what “true M4A” is - is that one that enslaves all the current healthcare providers and forbids them from working other jobs or in private practice or setting their own prices? Because what Obamacare did and what Warren says about “cost control” basically amounts to cutting reimbursements to doctors and if the doctors have any choice, they’ll not take patients who don’t pay them enough to cover their costs. This is why only half of doctors take Medicaid, which only pays about 60% of U&C, while only about 80% doctors accept Medicare, which pays about 80% of U&C. Surely if you could get enough private insurance patients for 100% or more of U&C, why wouldn’t you? Maybe the worst doctors who couldn’t cut it in private practice can find a place in Warren’s M4A plan the same way poor quality doctors are disproportionately represented in the cut rate Obamacare networks. This is the same reason more doctors are moving into concierge medicine, where they don’t have to deal with all the government or insurance company admin/bureaucracy and their low payment rates.

To the contrary, private insurance is what prevents, or at least substantially hinders, your ability to pick or keep your doctor.

M4A means you no longer have a choice of networks or insurance, so you can’t pick a plan the covers the doctors you want. How is no choice worse than more choice when it comes to getting the medical care you want? Worst case you can still pay out of pocket in the current system; I’m not sure that would even be allowed in a M4A system ala Canada (which bans private insurance and price caps doctors to their public reimbursement rates in most provinces, a combination which means there’s very little in the way of private medine for non-elective care). Sure, you might have to pay for it, but at least you can instead of being stuck with long wait times for subpar medical outcomes ala the U.K. NHS.

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Nope. I have no idea what “M4A” you’re talking about. Here’s S. 1129, which is the Senate bill cosponsored by Sanders, Warren, and others:

The House bill contains similar provisions, but does appear to be more limiting: it appears to prevent a participating provider from also providing covered services on a non-participating basis. (I believe this is a restriction private insurers impose on their participating providers as well. At least, I’ve never had a doctor tell me they can get me in quicker or something if I choose to pay cash instead of using my insurance that they’re in network for.)

The ACA did no such thing on the private side.

One of the advantages of a single payer is the negotiating power that payer has. That’s not to say I think we should squeeze providers – I think they should get a fair deal (caveat, of course, that “fair” isn’t really a black and white definition) – but it does allow us to eliminate the most blatant gouging, like what you see in pharmaceuticals. There might end up being a large market for private care in the Hamptons, but in the rest of the country, providers who want to stay in business (with only a small, niche exception) are going to have to take Medicare.

I don’t think anyone disputes that Medicaid reimbursements are below cost, but I’m inclined to believe the same argument for Medicare is just Hollywood accounting. Regardless, a comparison of current Medicare rates to current costs is not appropriate. M4A under either bill will substantially reduce administrative costs, eliminate uncompensated care, and also will have the result of bringing those below-cost Medicaid reimbursements up. A proper comparison needs to take into account these factors.

We spend roughly twice as much on health care as the rest of the developed world, for (at best) similar outcomes. There’s a lot of room to cut without negatively impacting quality.

Also:

  1. What you have is the illusion of choice, not choice. Your employer (and/or your spouse’s employer, if applicable) chooses the network(s) available to you, and I think it’s a rarity for employers to offer the choice of multiple non-HMO networks.

  2. How is it more favorable to be able to choose between networks that by definition limit your choice in some way, than to be part of a single universal network that covers all Americans? When one network covers everyone, providers who want to stay in business (and aren’t catering to the very well-off who do pay privately) are going to have to participate in some way.

My point about enslaving the current healthcare workers was that if you’re not willing to do that, which no one is proposing of course, you can’t force the doctors to work for low wages or even as doctors at all. As such, if you try to cut their reimbursement rates as Warren proposes to below the current Medicare levels, you will see many of the good doctors retiring, going purely private, or doing some other job. In any of those cases, M4A doesn’t allow you to “keep your doctor” just like the ACA didn’t, or at least it won’t cover them which makes it worse than the current system for someone wanting to keep their currently insured doctor. As a side note, increasing demand for healthcare services, which presumably is what happens when everyone can now get all the healthcare they want “for free” (including many who many not have any or as comprehensive coverage), with reduced economic incentives for doctors to continue to practice medine through cost cutting, is a recipe for exploding wait times and healthcare rationing.

The parts of the law you cite about prohibiting private insurance for covered / duplicated benefits combined with not letting doctors earn anything from private practice if they take M4A reimbursements, should be expected to lead to almost no private non-elective medicine as it has in Canada where the laws are similar. For example, under this M4A law, if you didn’t like waiting say 2 months for your cancer follow up (try not to have it advance to a worse stage in the meanwhile), you couldn’t buy supplemental or private insurance to pay extra to get a doctor to see you promptly since that service would be covered, eventually, under the M4A plan. So basically you have no private insurance market, so while there can be purely private doctors, they both 1) have to support themselves entirely from their non-M4A business and 2) their clients have to pay entirely out of pocket without any risk pooling benefits of insurance. This is clearly much worse for free choice than the current system, and less efficient in terms of risk reduction. These are the costs of the rules needed to enforce the government monopoly.

You’ll have to forgive me for being skeptical that putting the government in charge of administration will lead to cost savings over the private sector. Yes, the insurance company model isn’t good on this front, but the government has a really terrible track record and no incentives to care about cost overruns or other people’s delayed healthcare treatments.

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Apropos so-called Medicare efficiency vs. private insurance

Malcolm K. Sparrow, a professor at the Kennedy School of Government at Harvard University whose book License to Steal is a classic in the field, thinks that Medicare’s fraud-related losses may run “as high as 35%” of its budget.

An infinitesimal amount of Medicare’s budget is spent on fraud detection, so yes, it is easy to get to 98% claim payment when 1 in every 3 claims you pay is fraudulent and you spend little to no time detecting fraud. The less effort Medicare takes to prevent fraud and the more money it lavishes on criminals, the more efficient it looks. (Source for these stats: “Overcharged: Why Americans Pay Too Much for Health Care” by Charles Silver, David A. Hyman Chapter 16.)

Sure it did - it just did so indirectly through the insurance companies. When faced with adverse selection in the ACA risk pool, mandated high benefit coverage policies, and political pressure to keep headline premiums low initially, the insurance companies reacted by both 1) jacking premiums at double digit rates for several years, and 2) creating special “narrow networks” of select low-cost providers who were willing to offer their services to get additional clients since they couldn’t attract enough otherwise (doesn’t make you think they’re the top of the heap).

the push for more restrictive networks comes represents an attempt on the side of health payers to reduce monthly premiums and care costs at the expense of beneficiary choice.

I had first hand experience with this where many of the ACA network doctors in my region either dropped the ACA plan shortly after finding out how much their reimbursements would be, or if you found a good doctor, they would often stop accepting your ACA plan in a year or two. Mind you they might still take BC/BS, just not the ACA exchange plan from BC/BS.

I care a lot about choice, and my setup is such that I choose the group insurance provider I want based on the plan and network I want each year. There are several providers and from each there are many variations of plan types - HMO/EPO, PPO, HDHP eligible ones, maybe POS, etc.

My point is that in the process of trying to force all the providers into a single network, you’ll end up losing many of the good ones so claiming you’ll get more choice is the illusion. What good is choice if they aren’t the ones you want?

None of the top cancer hospitals for example in several major metros areas I’m familiar with are covered by any ACA plan offered there. That’s when I decided these ACA plans were worthless to me, since if I actually had that problem I’d want to pay for a top hospital to treat it and if they didn’t cover my tail risks for cases like that, what good was the insurance? (never mind it was a terrible deal actuarially due to me being on the wrong end of the ACA demographic redistribution policies). Whose to say the same economic incentives that lead these cancer research hospitals to decline to accept ACA plans won’t also lead them to decline to take M4A?

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I saw a quote somewhere recently that said, roughly, private profits are the price of efficiency. If you let the private sector provide something, it will do so with high efficiency to generate profit for the owners by cutting out waste and fraud, developing better technology/tools, etc. If you let the government do it, you have lots more waste since there are no profits to care about to incentivize the bureaucrats. You pay one way or the other, but the free market gives you a lot more choice most of the time. Admittedly healthcare in the US is not a particularly free market, but it’s still way more so than a single payer or single provider model.

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I disagree with the conflation of “healthcare” and “health insurance”. If you believe that everyone is entitled to healthcare, I disagree with concocting a convoluted means of paying for it “like everyone else”. I think free services should be delivered via “free clinic” type avenues, while those that want to purchase insurance and/or pay private providers for better options can do so on their own volition. It’s not unfair to poor people, it’s a perk for those who’ve obtained financial success - one of the core principles of capitalism.

That said, if “we” are hellbent on providing healthcare to everyone via some kind of health insurance smoke and mirrors, I do agree that the whole “medicare for all” concept is how it should occur. Whatever is deemed essential services everyone is entitled to, is what should be covered by Medicare. But nothing more, at all - very specific and straightforward coverage, no "if"s "but"s or other contingencies or tiers, everyone gets the same, no more and no less. Then leave it to individuals to purchase any services or insurance/coverages they choose beyond that.

Of course, I’d also expect top doctors to start charging patients an annual membership fee or cover charge, just to get on the books to receive that “free” cut-rate medicare-funded care. With that membership fee being part of the additional coverage provided by private insurance.

Your underlying assumption seems to be that an M4A plan is going to cut provider reimbursements to some unsustainable level that will cause a bunch of doctors to go find jobs in other fields. That’s not a given. The reimbursement structure is an implementation detail.

Warren’s plan does no such thing:

“Current Medicare rates” are not “below the current Medicare levels.”

Hospitals would get 110% of current Medicare rates, with upwards adjustments for certain cases:

The only thing resembling cuts is:

But that’s explicitly a budget-neutral redistribution between types of doctors. (I have no position currently on whether such a redistribution is appropriate, as I haven’t done any analysis on the topic.)

Your other underlying assumption seems to be that current Medicare rates are inadequate to sustain a business without other higher-paying (private) patients. Even if we assume this claim is true, it can only be said to apply to the current system. You cannot say it applies to Sanders’ or Warren’s M4A plans without conducting a further analysis that takes into account the reduced administrative costs on the provider side, elimination of uncompensated care, and increase of current Medicaid payments to the new M4A levels.

(I am intentionally not responding to the rest of this sentence, because I believe it would be redundant.)

This, I suppose, is related to one’s value system. I happen to believe health care is a human right, and my positions here are consistent with that:

If demand is increased because people who needed health care in the past and were unable to get it can now get it, I consider that desirable. If there’s a mismatch between supply and demand, then yes, we have to ration care based on need. I also consider that desirable. The alternative – the status quo – is to ration care based on ability to pay. And it turns out that we, as a society, aren’t exactly comfortable with explicitly saying that, which is why emergency rooms are required to provide emergency care regardless of ability to pay. As such, I don’t think this is a particularly radical position of mine. (Speaking strictly from a financial sense, this is an absurd way to structure a healthcare system. It’s far cheaper, for example, to give a diabetic insulin than it is to let them go without it for financial reasons and pay for the resulting ICU visit.)

You address a shortage with supply-side policies, which can include increasing pay. I believe there is room to do this if necessary while still reducing overall costs and providing high quality care. And the reason I believe this is because literally every other developed country has managed to do it. (That source doesn’t reflect on outcomes, but I don’t think it is disputed that overall – not singling out any particular country or countries, just overall – care quality in the developed world ex-US is competitive with the US. There are other sources that provide relevant data, if needed.)

Even if you take the GDP data at face value (linking to Wikipedia because they aggregate other cited sources), including the absurdity of the GDP of tax havens being measured based on those sham financial transactions, we are one of the richest countries in the world. (And in a proper comparison, I’d look for a way to take the tax haven nonsense out of the equation.) We are not lacking in resources. We have the resources to provide health care to all of our citizens, and I believe we should do so. Others’ views may differ.

This is a legal interpretation question and needs clarification. The way I interpret the M4A bills, the prohibition is strictly against selling duplicative coverage. The M4A system would not cover non-participating providers, so an insurance plan (which could be provided by an employer or otherwise) that provides coverage at a private hospital (which is a non-participating provider) shouldn’t be duplicative. At least that’s the way I interpret it, but I may be wrong.

If my interpretation is correct, this would be a system similar to the one in the UK, where private hospitals (and other facilities) and insurance are very much a thing.

Purely speculative. If rationing is necessary, it should be based on need, not ability to pay as it is today, IMO.

This is philosophical. Government works fine when not being run by saboteurs.

I think Bill Black, a former S&L regulator in the S&L crisis days, puts it better than I can:

At least I can vote for my political representatives. That’s more power than I have over an insurance company.

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And what are the losses in the private market? The limited data available is not pretty.

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