Make no Mistake about It, Project 2025 is Powerful, it is Well-Funded, and it is Religiously Extremist, Misogynistic, and White Supremacist.
Last August, this headline appeared in the Washington Times: “Recruiting is underway for Trump-like ‘wrecking ball’ to shrink government and fire federal workers”[1]The wrecking ball to which the article was referring is a cadre of extremist right-wing individuals who will, if Trump wins in November, see to it that their allies staff his administration. The powerful, anti-Democratic Heritage Foundation has initiated a movement dubbed “Project 2025,” – a network of Christian Nationalist, states’ rights’, anti-choice, school censorship, and anti-constitution organizations steeped in religious zealotry and as far out on the right of the political spectrum as any movement in U.S. history.
The Heritage Foundation is claiming that 100 organization on the hard right have signed onto their project in preparation for ending U.S. Constitutional government as we know it.[2] They are intent on scrapping the form of federalism intended by the framers and accepted by the American people as it has evolved since 1789. The list of organizations signing on includes Moms for Liberty, Turning Point USA, Hillsdale College, Liberty University, Susan B. Anthony Pro Life America, Dr. James Dobson Family Institute, Family Research Council, and other reactionary groups.
Most people who pay attention to politics have heard of at least one or more of these fanatical groups. Adherents of the Moms for Liberty have been running around censoring books in school libraries. They are allied with DeSantis’s project to undermine public education and replace it with a revisionist, false history and toxic religious indoctrination. Turning Point USA was formed and led by Charlie Kirk a rabid disseminator of disinformation and supporter of Donald Trump and his tripe about stolen elections, insurrectionists as patriots & hostages, and other dangerous nonsense. He has successfully organized chapters on at least 400 college campuses.
These types of anti-American organizations have moved from the unthinkable to the normal in the past few decades. Even more diabolical and violent groups are lurking in the shadows of this cabal. The violent, neo-Nazi Proud Boys and other Hitler sympathizing white male organizations are operating on the perimeter of the movement and tolerated at meetings of CPAC and Turning Point USA.[3]
Project 2025 is in Sync with the Ultra Conservative, Six Member Supreme Court Majority and the Republican Party
The current six-member majority on the U.S. Supreme court is acting not as jurists but rather as idealogues with sympathies for the dominant and dogmatic religious leaders of the Republican Party and a very mentally disturbed Donald Trump. Mainstream legal scholars are horrified by their actions and are speaking out about it[4] – to no avail. Not only is the overtly ideological majority on the court signaling that they will seriously weaken federal agencies,[5] they are expressing a considerable amount of sympathy for reducing women to second class status,[6] and interfering with privacy rights of gay and heterosexual married couples.[7]
It also appears that the S.C. majority has piled weight on the scales of justice for Donald Trump who is attempting to forestall his criminal trials by claiming total immunity for anything he did as president. This is an absurd claim rejected by a unanimous three judge panel of U.S. Court of Appeals for the District of Columbia Circuit. Nevertheless, the S.C. decided to hear the case and help stall justice for the American people who need a decision prior to the November 4th election.
Rarely in U.S history has the Supreme Court issued rulings that retract previously granted liberties. However, this court is intent on remaking law to reflect their favoritism toward a fundamentalist Christian theocracy with concentrated power in the hands of ultra-conservative white males.
What Project 2025 Means for the Elders of America
Like other vulnerable groups in American society, the elderly are falling prey to economic predators. This is consistently becoming a bigger problem, but it is happening without adequate federal regulation. This is particularly the case for elders institutionalized in “nursing homes.” Lax oversight of the nursing home industry prior to 2020 and the spread of COVID led to 2000 patient and 200 employee deaths. This was preventable and shouldn’t have happened. Nevertheless, the media, white-washing commissions, government agencies, and the legal system have displayed no propensity to hold the industry accountable for its neglect.
While the scourge was killing and isolating nursing home patients, the right-wing media and politicians and pundits appearing on their networks were claiming that masking, isolating, and preventative behaviors in general weren’t necessary because as Bill O’Reilly mused on Fox News: “The [U.S. death] projections that you just mentioned are down to 60,000, I don’t think it will be that high. 13,000 dead now in the USA. Many people who are dying, both here and around the world, were on their last legs anyway.”[8]
O’Reilly’s attitude reflects a far wider viewpoint about the value of older Americans than our government and politicians would care to admit – even beyond the confines of the radical right. However, the strength of an underlying theological dominionist[9], government-hating religiosity – combined with grievances against liberal, women, gay, ethnic, transgender, and other non-white male outgroups – does not bode well for programs such as Social Security, Medicare, and humane care for frail elders. Crazy religious views of the extreme right have incorporated a glorification of private corporations and privatization of government services. This is an outgrowth of their hatred of liberal programs from the New Deal forward and the political liberalism that era implies.
Summary
Religious fanatics want to run America. They have made significant inroads in doing just that (think school vouchers). The Christian extremist alliance with violent, neo-Nazi organizations is even more disturbing. Under the influence of the Heritage Foundation for the past fifty years and now its Project 2025, this coterie is infecting the mainstream of U.S. political discourse and jelling into a real threat to our constitutional form of government.
Coverage of right-wing fanaticism by the mainstream media has been problematic. The Heritage Foundation was formed by wealthy individuals on the far right in the 1970s. At the time, it was considered too radical for the normal American politically centered zeitgeist. By the 1980s, representatives of the organization were invited as guests on moderate news outlets such as PBS News Hour and it became a go to entity for print media seeking what they believed to be normal conservative views.
The MSM tends to engage in a misguided form of “fair and balanced” coverage of political groups with the chutzpa to push unthinkable views hard enough and long enough to become accepted into the Washington, D.C. establishment. The undeserved respect these entities receive inside the D.C. beltway – including by the press – creates a form of induced ambiguity in mass communication and voters’ thought processes. The real danger and odious facets of the Heritage Foundation and Project 2025 are minimized in leading new outlets out of respect for their success in becoming part of the normal political establishment.
I’m worried about the level of energy exerted by moderates in pushing back on the well-organized and aggressive organizations constituting Project 2025. Furthermore, there should be vocal opposition to the media myth about a “divided country” as if there are two equally legitimate sides in U.S. politics. In truth, American political views can be characterized as a broad, ambivalent middle with loud minorities on the fringes. The loudest and most effective fringe voice these days is on the right. Is it even fringe any longer?
[7] In Dobbs v. Jackson, Clarence Thomas expressed interest in overturning the right to contraceptives – a right granted in Griswold v. Connecticut, 381 U.S. 479 (1965) – and the right of gay people to marry, which was accorded in Obergefell v. Hodges, 576 U.S. 644 (2015).
[9] Along with misogyny and white supremacy, Dominionism is one of the more perverse political philosophies driving the Christian Nationalist movement. Proponents of this weird and dangerous philosophy are increasingly successful in persuading the Republican Party to seriously consider and adopt their ideas. Dominion theology includes a belief in a Christian nation ruled on biblical tenets – whatever those may be. Many of the opponents of imaginary “woke education” would replace it with false teaching about the framers’ intent, which they claim was to create a “Christian Nation.”
Stealing from Taxpayers is Kleptocratic Behavior in Any Government
After the collapse of the Soviet Union, Russia began to transition from totalitarian communism to an oligarchy of politically connected apparatchiks and mobsters from the Soviet era. The productive sectors of the economy such as oil and gas and manufacturing were looted in a crude takeover by a powerful criminal cabal including the KGB and high officials of the Communist Party. There was nothing subtle about it. The economy was dismantled and carried off by an in-group of thieves and criminal enterprises. The health and lifestyle of the Russian people dropped precipitously. There was no longer any pretense about an economy designed for the rise of the workers. That era was over and kleptocracy became de rigueur.[1]
“The kleptocratic facet of the current U.S. economic dark age is far more refined than the brutish nature of the Russian oligarchy.“
As Soviet Communism was failing, the United States was transitioning from a “golden age of capitalism” to a dark age of government regulatory retrenchment, Wall Street dominance, loss of faith in government for the general welfare, a sinking middle class, stagnant working-class wages, and deteriorating population health. The kleptocratic facet of the current U.S. economic dark age is far more refined than the brutish nature of the Russian oligarchy. The conditioning of the American people has been sophisticated and in most instances difficult to recognize.
The kleptocrats of Russia merely took what they wanted right out in the open. U.S. kleptocrats applied an abstruse intellectual justification for weakening government checks and balances, dismantling regulatory agencies, and privatizing government services. Mythical beliefs about a nonexistent free market were generated in leading universities and sold to legislators and the public. Hence, a thing no more real than a unicorn was concocted by academic economists and marketed as the ultimate decision maker. The idea of “the market” was reified into an entity – an entity has never been observed or measured – endowed by theorists with complete knowledge and the ability to make the best decision about how government should work vis a vis private industry.[2] Indeed, it has been working increasingly well for the rich and powerful.
A Kleptocrat by Any Other Name is Still a Kleptocrat: An Example
Peter G. Peterson: Multi-Billionaire Founder of Blackstone
The late multi-billionaire Peter G. Peterson along with Stephen Schwartzman, founded the Blackstone Group, a financial services conglomerate. Mr. Peterson dedicated a billion dollars to the privatization of Social Security and Medicare. The trillions of dollars expended by the SS Trust Fund and Medicare program make an inviting target for a vulture capitalist. Unfortunately, Peterson had a stellar reputation inside the Washington, D.C. beltway where cliques of corporate and individual wealth roam. His front groups such as the Committee for a Responsible Federal Budget (CRFB), the Concord Coalition, and the Peter G. Peterson Foundation, jelled into a highly influential network of “go to” organizations for public policy.
Maya MacGuinness, CEO of CRFB, is frequently the only person quoted when federal budgeting is covered in leading mainstream publications such as the New York Times. Her mantra is that Social Security and Medicare are leading causes of budget deficits. This is not true and she either knows that and is lying or she is seriously incompetent and ill informed. Either way, representatives of mainstream media – including PBS – are irresponsible for consulting her.
Medicare is undergoing rapid privatization, and an increasing amount of public funds are diverted from care to a bevy of private for-profit financial intermediaries. This has increased the cost of Medicare. But this increased expenditure is not devoted to better care. Rather it is siphoned off into shareholder earnings and benefits a few wealthy individuals.
Medicare wasn’t privatized solely under the influence of Peter G. Peterson. The Medicare Modernization Act of 2003 included Part D – a prescription drug benefit – and was pushed by Big Pharma. The insurance industry pushed the act because it included Part C – privatization of the entire program under what has become known as Medicare Advantage.
Social Security remains un-privatized and administered at a cost of ½ of 1 percent of revenue. Wall Street would love to privatize it in the same manner as Medicare and earn huge management fees that would rake off up to 25% of revenue, which has been the experience in the privatized Chile SS program.
Nursing Home Kleptocrats
“It is a shabby business carried out by sleazy businessmen in a weakly regulated government funded skilled nursing system.“
Investors have a vast interest in frail elderly and disabled Americans institutionalized in the disgraceful U.S. nursing home system. They can get by with a minimal, substandard, quality of care while extracting and pocketing optimal amounts of cash. It is a shabby business carried out by sleazy businessmen in a weakly regulated government funded skilled nursing system.
A richly funded propaganda machine and political contributions are responsible for a veil of secrecy around the corruption of an industry with little interest in optimal care of the people in their charge and from whom they are expropriating assets that would otherwise be passed to their heirs, thereby causing even more maldistribution of wealth. While tunnelling excess amounts of government provided revenue through subsidiaries and shell companies, they have effectuated a first-class propaganda machine that has sold lies about financial hardship and underfunding from government. I even see this lie promoted in peer reviewed journals – mostly from economists.
Propaganda works. The industry lobby has an effective PR campaign that leads the public to believe that it is tough to make money running nursing homes. They rely on the lack of financial literacy among most people by noting a general low operating margin reported by most facilities. These misleading statements regarding nursing home facility cost reports submitted to state regulators and CMS are often taken at face value by academics, the media, and advocates. Consequently, supposedly peer reviewed publications include findings from data dumps of information taken from facility-specific reports.
Right Wing Fanaticism Didn’t Shrink Government. However, It Did Shrink Democracy.
A well-known anti-government fanatic once said that he wanted to shrink government down to a size small enough that he could drag it into the bathroom and drown it in the toilet. Cute. Grover Nordquist is the guy we are talking about here. Although he is clearly an idiot, politicians have lived in mortal fear of his condemnation and avoided any hint that they might raise taxes – meaning individual and corporate taxes. Reaganites, Nordquististas, Paul-groupies (Ron and Rand) and indeed the libertarian extremist, government hating, right-wing of American politics believe that taxes feed “the beast.” So, they were successful in collapsing individual income tax brackets, lowering corporate income taxes, and devolving taxes to the states in the form of regressive sales, excise, and user taxes. At the same time, executive branch agencies with the purpose of protecting the public from corruption and abuse and implementing legislation have been weakened considerably.
“Along with privatization of government services – especially healthcare – a weakened regulatory system has been conducive to a refined form of looting….”
The middle- and lower-income classes are not paying lower taxes. Billionaires and corporations are. Furthermore, an increasing amount of middle- and lower-class income and wealth is being distributed to families and individuals with the highest level of income and wealth (think “spend downs” in nursing homes). Along with privatization of government services – especially healthcare – a weakened regulatory system has been conducive to a refined form of looting through Medicare, Affordable Care Act, Medicaid, Pentagon/defense budgeting, and a multitude of other forms of privatization. Well, maybe not so refined, if we just take a closer look at it.
Without a robust federal regulatory framework, the rights of Americans are now trampled by special interests who have been able to tilt the tax codes in their favor and takeover government services at costs higher than would be if the services were provided by federal agencies. One unfortunate result of this form of looting is that Americans are increasingly gouged by health insurers and paying more than their peers in Asia and Europe, but their overall health is worsening.
The U.S. Supreme Court is About to Seriously Dilute Executive Branch Regulatory Power
Federal laws can be sweeping and complex. The Clean Water Act, the Occupational Safety & Health Act, and the Medicare Modernization Act are examples of laws that have induced systemic change in U.S. government and society. These laws cannot anticipate, nor can they address every contingency in day-to-day implementation. Congress has traditionally considered technically qualified agency personnel to be responsible for filling in the “gaps” in highly complex legislation.
Industries affected by major legislative changes have typically fought administrative regulations issued by the EPA, OSHA, FDA, and a host of other regulatory agencies. They have attempted to blunt regulations through the courts, propaganda, and the political process. However, in the 1984 case Chevron USA, Inc v. The Natural Resources Defense Council, Inc., the Supreme Court enhanced the legitimacy and legality of agency regulations and strengthened Executive Branch oversight. The Court held that deference should be accorded to administrative agencies with the technical capability and scientific knowledge for addressing ambiguous issues in legislation.
That precedent is likely to be overturned when the Court hands down decisions on two cases already heard this session: Loper Bright Enterprises v. Raimondo and Relentless, Inc. v. Department of Commerce. The cases concern regulations issued by National Marine Fisheries Service (NMFS) under the Magnuson-Stevens Fishery Conservation and Management Act (MSA). The forthcoming decisions will address two major questions:
1. Should Chevron v. Natural Resources Defense Council be overruled?
2. Does statutory silence concerning controversial powers expressly but narrowly granted elsewhere in the statute constitute an ambiguity requiring deference to the agency?[3]
The six conservative idealogues on the court are expected to answer question 1 in the affirmative and question 2 in the negative. This is a particularly horrendous prospect for the U.S. healthcare system, which has outsourced trillions of dollars to some of the largest corporations in the United States. These corporate behemoths with very deep pockets or trade associations with vast resources will take their dislike of particular regulations into court and will often find friendly judges who will interpret regulations in their favor even though they – the judges – will have no scientific credentials to make technical decisions. This has already occurred in the Alliance for Hippocratic Medicine v. U.S. Food & Drug Administration[4], which was heard before the Supreme Court last week.
In that case, a federal judge in West Texas issued a ruling that overrides the scientific research undertaken by the FDA in the approval process for mifepristone (also known as “RU486” and “Mifepristone”) – more commonly called “an abortion pill.” The S.C. will no doubt find that there is no standing to sue on the part of the anti-abortion doctors. Nevertheless, the question of whether a judge can override reasonable regulations issued by the FDA will be left open. That is where this case intersects with the Chevron deference principle that will most likely be overturned.
This does not bode well for women’s reproductive rights specifically and for healthcare in the U.S. generally. As these court cases pertain to kleptocracy, a corporate friendly and extreme right-wing majority on the S.C. is in a position to neuter federal agencies and strengthen the hand of kleptocrats.
Summary
Acts of government sanctioned cheating and stealing from the American people are permeating the multi-trillion-dollar government funded healthcare system. As government funded medical care is increasingly privatized and corporations in the business become bigger and more powerful than the agencies regulating them, more funds will be diverted illegally from care into owners’ pockets. For instance, I’ve noticed an increasing number of nursing home facilities maltreating and underpaying employees, which discourages applicants for work and induces turnover. At the same time, they contract for labor from subsidiaries of their parent/holding companies at an extremely high rate. We have examples of facilities contracting with related parties for 50 to 63 percent of their labor. State and federal agencies have failed to even notice let alone deal with this egregiously illicit practice.
This example of labor contracting is only one of many, many forms of cheating. MCOs often deny authorization for physician prescribed treatment in their networks to keep their cost below capitation rates. Hiding and distorting information on cost reports, overcharging for services, upcoding therapy services, funneling funds through shell companies to hide excessive extraction of funds, and pressuring congress through bribes (campaign contributions) to unjustifiably increasing reimbursement, i.e., rent seeking are a few more examples of cheating and stealing. It should come as no surprise that the American people pay two to three times more per capita for healthcare than the people of our Asian and European peer countries with universal, single payer, government managed healthcare systems.
My purpose in writing this blog post is to encourage attention to psycholinguistics in advocacy, scholarship, and public discourse in general. Professionals and scholars are reticent about applying terms such as kleptocratic to behaviors that are best described as that. The media avoids harsh and condemnatory terminology – even when it called for in describing events and acts.
Stealing is stealing, thievery is thievery, whether they happen through a home/business break-in, or through cheating on forms submitted to the federal and state governments. White collar crime is unfortunately placed on a higher plane and is less punishable than street crime generally committed by the poor and powerless members of society. How we describe behaviors and what we call them has significant influence on how they are perceived and treated in political discourse and the criminal justice system.
[1] Terms such as plutocracy, oligarchy, and kleptocracy are not mere words and are not used in this blog for name calling. In public discourse words should be taken seriously and utilized in a technically correct manner as scholars in political philosophy would theoretically utilize them.. Kleptocracy is defined as: “ a form of government by individuals who primarily seek personal gain at the expense of those they govern.” Kleptocracy | Definition, Examples, Kleptocratic Leaders, Dekleptification, & Facts | Britannica.” Given this broad definition of kleptocratic behavior, examples of it abound in the U.S. and are manifested even more crudely in Russia. Terms such as oligarchy, plutocracy, and kleptocracy can all apply to any one government in any one nation state. Oligarchy pertains to rule by a small number of individuals sans democracy. Plutocracy is rule by the wealthy – also contrary to democratic governance. As wealth is distributed away from the masses to a small number of superrich individuals, plutocracy is intensified and becomes more salient in political processes. Hence, the system becomes more oligarchic because the power is posited in a smaller number of individuals. The intersectionality of plutocracy and oligarchy is of importance in this discussion. Furthermore, the correlative increase of rule by the few in their private interest, contrary to the public interest, and the concentration of wealth in a tiny minority leads to corruption on a wide scale. Therefore, resources that could be dedicated to elevating the health and lifestyle of the masses are diverted to a wealthy few. For instance, government tax receipts flowing from wage and salary earners have been increasingly and excessively diverted to shareholders at the expense of government services intended to improve the health and welfare of all classes of U.S. residents. Kleptocratic behavior is expressed in the healthcare system by the proliferating number of financial intermediaries such as insurance companies, pharmacy benefit managers, etc. who drain resources from care without adding effectiveness and efficiency to the overall system.
[2] Reification is a frequent fallacy in pseudoscientific thought processes. Naming and describing something abstractly do not prove that the thing exists concretely. The free market as an abstraction is a description of trillions of daily interactions in which people buy and sell things. It is fallacious to call all of those interactions a thing.
Anyone who has a regular medication regimen is usually quick to lament how costly it is. Well, you know, drugs are expensive, especially in America! But, what is the industry structure that determines and manages the price? The answer is found in a middleman enterprise known as the PBM, an acronym for Pharmacy Benefit Management. This acronym can also double as an oxymoron for patients who need medications because they are not benefiting from this interference in the system. Profit By Middlemen might be a more honest label.
“Profit By Middlemen by might be a more accurate explanation”
Most Americans have no awareness of the methods used to control and manage the cost of drugs they are prescribed. Their normal routine is to inform their doctor what pharmacy locations they visit to acquire their medications. And that is where their knowledge of the pharma industry ecosystem stops. Their doctor calls in the script, and they just drop by to pick it up. The process in the past of being handed a piece of paper from a prescription pad with a scribbled signature is long behind us.
PBM definition
The definition of PBMs can vary greatly depending on the source. It is by any measure a controversial element of the Medical-Industrial Complex. Industry advocates will claim without a means of proof that the purpose of a PBM is to reduce the cost of medications to insurance companies, that ultimately passes through to patients. That may have been the original intention and purpose, but there is no visible transparency that can clearly verify that fact. PBMs are middleman businesses that opaquely work both ends against the center. Study the graphic at the end of this article.
“PBMs are middleman businesses that opaquely work both ends against the center..”
In essence, their role is to negotiate drug pricing directly with the pharmaceutical manufacturer. They have contracts with the giants in the insurance industry who hire them to perform this task, and that gives PBMs considerable pricing leverage with the pharma manufacturers.
Do PBMs Actually Benefit Patients?
Theoretically, this service would lower the final cost to the patient. But as it turns out, it often causes price increases to that patient. The PBM earns money by charging their customer, the insurance company, a fee. They also mark up the cost they negotiate for the drugs to create a margin that results in additional income. To the tune of $500 billion per year. There is no transparency in this process. I will share more about that later in this article.
Origin and History
PBMs first came on the medical industry scene in 1968, but they were not called that initially. The first iteration was called the Pharmaceutical Card System. United Healthcare was involved from the start, and therein lies one of the problems with this concept. The clear conflict of interest is a major and unavoidable factor. And it has proven to be obscenely profitable for them.
Today, due to a continuous progression of industry consolidation there are three giants in this space that control about 80% of the total PBM market. They are Caremark owned by CVS, OptumRX owned by United Healthcare, and Express Scripts owned by Medco Health Solutions.
The MIDDLEMAN issue
It is often not wise to trust any middleman source on the surface. There may be instances and examples in business that prove middlemen to be beneficial. But more often than not, it is usually a rent-seeking enterprise that results in elevating the cost of a service or product to the end user.
“There is no sufficient way to verify if savings are realized by the customer…”
There is no sufficient way to verify if savings of any consequence are passed on to the final consumer. An industry lobbying organization claims that roughly $43 billion per year will be saved by the PBM business model over the next ten years. Even if that can be proven, earnings of $500 billion per year only yielding ten percent in cost reduction is not an impressive ratio.
Transparency, as in not any…
The PBM industry has attracted much controversy, leading to a substantial volume of litigation due for the most part to the opaqueness of the business model. PBMs demand pharmaceutical manufacturers and pharmacies keep their cost amounts confidential. The margins PBMs realize in their pricing structure are closely held secrets. PBMs also do not permit pharmacies to recommend lower cost alternatives unless they are specifically asked to do so by their customers. The margins are much more profitable for the PBMs when the drugs are higher priced.
“The margins PBMs realize in their pricing structure are closely held secrets…”
Another contentious factor between PBMs and pharmacies relates to control of dispensing fees. It is dictated to pharmacies what they can add to the cost of filling a prescription. PBMs have seemingly captured too much control over the entire industry that has resulted in higher costs rather than savings passed on to the end user.
A Voice From Behind the Pharmacy Counter
I questioned a friend who has been a practicing pharmacist for several decades. He has seen a vast alteration of the pharmacy landscape during his years in the business. Moreover, his father was also a pharmacist who practiced for 50 years, and owned drugstores in multiple towns, back when that was definitive of what they were. His experience spans a variety of pharma business verticals, from independent pharmacies to national corporate chain stores, clinical pharmacies within hospitals, and managing clinical trials. During his career, he has seen and experienced the full spectrum of the pharmaceutical ecosystem. He had a lot to say about PBMs and their unwelcome effects.
Some examples include; a lack of transparency, rebate practices, spread pricing, limited pharmacy networks, high out-of-pocket costs for some patients, the Impact on independent pharmacies (low reimbursement rates and restrictive networks), and some PBMs are vertically integrated with health insurers or pharmacy chains, which can create potential conflicts of interest and reduce competition in the market.
Pharmacies acquired their inventories before the advent of PBMs either through major distribution channels that served as the original intermediaries between the manufacturer and the drugstore, or directly from the manufacturer. There were, and still are, pharmacists who are skilled in compounding medications. You can probably find one in your area if you search carefully enough. Compounding pharmacists create personalized medications by combining, mixing, or altering ingredients to meet the specific requirements of a patient’s medical condition, age, weight, allergies, or other factors.
Many aspects of practicing pharmacy changed when PBMs seized control of these earlier business methods, and not in a positive manner. A formulary today is not what it was decades ago. The PBM dictates what the formulary is today. The remuneration aspect of formularies, according to my friend, can absolutely and negatively impact the profitability of the business in a number of ways. It explains why a drugstore today is more like a minimart where the customer can also buy a gallon of milk, a quart of motor oil, and even toy wagon for a child. How about that candy aisle? There’s some health-conscious products for you!
About that income from filling a prescription? A medication costing $50.00 versus one that costs $500.00 results in virtually no difference in earnings for the pharmacy. The only difference is the burden of maintaining inventory. The margins are captured and controlled by the PBM, not the business where drugs are dispensed.
Patient Stories
What about from the patient perspective? Buying a prescription is a minefield today. It can feel like being a con man’s mark in far too many cases. But fortunately, conscientious pharmacists are siding with the patients more every day. Since pharmacists behind the counter are discouraged by PBMs from advising the customer regarding more economical alternatives to what has been prescribed, they have found ways to help the medication customer save money. One example is to provide a discount card they have on hand for the customer’s benefit.
“Customers are learning not to accept the first price they are given…”
Medication customers are learning not to accept the first price they are quoted. They are finding more affordable options by asking the pharmacist if a generic version is available. Pharmacists are instructed by PBMs not to volunteer that information, but to provide it when asked. People are also searching online for lower cost options when beginning the regimen does not require urgency or expediency.
I was recently told a story by a friend who diligently explored every option available and was able to reduce an initially quoted price of $50.00 down to $2.00. That is an extreme example, but it reveals the benefit of making the effort whenever possible.
Alternatives and Solutions
When the balance between efforts to monopolize any business sector and the customer base being served becomes too lopsided, it inevitably opens the door for disruption and new competition. Two present day disruptors to emerge are Mark Cuban Cost Plus Drugs, and Amazon Pharmacy. Mark Cuban aggressively negotiates with drug manufacturers and then adds 15% to the cost. This can result in remarkable savings in some cases. Amazon Pharmacy is accomplishing the same outcome due to the leverage they can exercise because of the size of their existing customer base.
It is highly likely there will be imitators entering the market in large numbers as they watch these two sources capture more and more market share over time. Also, it has been common practice for years for American pharmaceutical consumers to order their drugs from Canadian and Mexican sources when possible.
Study this innocuous appearing graphic carefully. When you read it closely, you may feel it obfuscates as much or more than it clarifies. Nevertheless, you can see the power PBMs have over the industry because they embed their business process into the most critical touch-points in the retail drug eco-system.
Most Americans have never heard of the Better Medicare Alliance[1] – a Washington, D.C. think tank and front group for big health insurers such as UnitedHealth, Aetna, and Humana. Also, the 2023 Super Bowl TV audience didn’t know who paid for a commercial at halftime claiming that President Biden had plans to “cut Medicare.” The ad included a message urging viewers to call the White House and “tell President Biden not to cut Medicare,”[2] but they – the TV viewers – didn’t know who was asking them to do it. Football fans had to be perplexed. Medicare beneficiaries were most likely upset and worried by what they saw and heard.
“One illegal practice health insurers utilize to add unearned value to their Medicare Advantage (MA) reimbursement is called “upcoding.”
The ad, funded by Better Medicare Alliance, was a lie. The truth is that President Biden had no intention and no plan to cut Medicare. Contrary to what the ad claimed, he was planning to claw back $4.7 billion from UnitedHealth and other insurers for defrauding the program through false billing practices. One illegal practice health insurers utilize to add unearned value to their Medicare Advantage (MA) reimbursement is called “upcoding.” Because sicker patients are reimbursed at a higher rate, the trick is to find ways to lie about how sick a patient is – to make them look sicker than they are.[3]
MA beneficiaries tend to be healthier than Traditional Medicare (TM) beneficiaries. Nevertheless, research indicates that when individuals move from TM to MA, their costs to the program increase. The important point is that “total Medicare payments to MA plans in 2024 (including rebates that finance extra benefits) are projected to be $83 billion higher than if MA enrollees were enrolled in FFS Medicare.” Furthermore, payments to MA plans average an estimated 122 percent of what Medicare would have expected to spend on MA enrollees if they were in FFS Medicare.”[4]
After the Biden Administration’s proposal to recoup stolen money from MA insurers and prevent further fraud, the health insurance industry threw a conniption fit and went into overdrive. The Super Bowl ad was only one tactic (costing eight figures, it was super expensive). In addition, they sent their army of lobbyists crawling all over the Washington, D.C. beltway threatening and bribing legislators. HHS backed down. The cheating continues and costs the seniors of America – indeed all wage earners – hundreds of billions from their payroll deductions, premiums, co-pays, and nearly $200 out of every Social Security check.
Pulling Back the Curtain on the Washington D.C. Policy Planning Network: What is the Better Medicare Alliance & Who is Behind It?
The insidious thing about think tanks set up inside the Washington, D.C. beltway is that they enlist the aid of seemingly legitimate advocates and scholars. It is hard to know if the advocates and scholars are merely naïve or whether they are self-serving. Perhaps unwitting would be a kinder word. For instance, the Better Medicare Alliance board consists of Dennis Borel, Executive Director of Texans with Disabilities, Caroline Coats, Humana, Inc., Daniel Dawes, Meharry Medical College, Mary Beth Dawes, Former Congresswoman (President & CEO), Joneigh Kaldhun, CVS Health, Dan Lowenstein, Visiting Nurse Service, NY, Richard Migliori, UnitedHealth, Elena Rios, National Hispanic Medical Association, and Kenneth Thorpe, Emory University.
The organizational structure of these industry front groups is a form of disinformation itself. On the board are big players in the MA industry – Humana, CVS, and UnitedHealth. Interspersed with the representatives of these health insurance behemoths are executives and professionals from organizations with an ostensible mission to improve society in some manner.
By placing their imprimatur on an industry lobbying group, NGOs, nonprofits with a stated humanitarian cause, and universities are participating in a duplicitous tactic to confuse the public about the real purpose of nefarious industry think tanks like Better Medicare Alliance. Their support for various entities with a mission to preserve and strengthen the medical-industrial complex helps divert funds needed for care into the coffers of executives and shareholders.
Privatizing Medicare was Supposed to Reduce Costs and Give Beneficiaries More Choice: It Hasn’t Worked Out that Way.
MA is a creature of the Medicare Modernization Act of 2003. The right-wing of American politics accomplished a coup by setting Medicare on the road to privatization. Currently over 50% of all beneficiaries have selected it over Traditional Medicare ™. Federal policy is unfortunately driving Seniors into MA by allowing manipulative practices such as low premiums and a few benefits not available to TA beneficiaries. Seniors are being led like lemmings into the arms of the insurance industry by disinformation and deceit. Organizations like the AARP in partnership with health insurers like UnitedHealth are the Pied Pipers.
MA is one of the most serious threats to the health and well-being of American seniors. It robs money from care and transfers it into the pockets of investors and executives. Many beneficiaries are happy with low premiums and add-ons not available under traditional Medicare such as Silver Sneakers plus some dental and vision care. I can understand why many people who have it are pleased with their coverage. It works for healthier beneficiaries until it doesn’t.
If MA beneficiaries should incur a costly service that is not in network, their assets could be wiped out. Some retirees have no choice in the matter. If their company or institution includes health insurance as a retirement benefit, it is most likely MA. Furthermore, I can’t blame anyone who is trying to avoid the premiums for supplemental coverage under traditional Medicare. Avoiding bankruptcy and depletion of assets through a catastrophic sickness makes perfect sense for TA beneficiaries. But the supplemental insurance is a heavy burden that could be avoided if the Medicare program weren’t diverting so much funding to MA (see discussion below).
Seniors and People with Disabilities Would not be Struggling as Much If Big Health Insurance were not Stealing from Them.
For seniors and disabled Americans to lose nearly $200 per month of their Social Security and choose between a large payout for supplemental or the risk of bankruptcy, is an injustice when privatized healthcare is stealing hundreds of billions of Americans’ tax dollars, payroll deductions, and hard-earned money through out-of-pocket expenses. The Physicians for a National Health Program (PNHP) has estimated that MA overcharged taxpayers by a minimum of 22% or $88 billion and potentially up to 35% for a total of $131 billion in 2022. If the high end of the estimate were correct, all of Part B premiums ($131 billion in 2022) or Part D premiums ($126 billion in 2022) could be covered by excessive corporate extraction of funds from Medicare.[5]
UnitedHealth is noting $25 billion in cash and cash equivalents on its 2023 balance sheet, CVS has noted $12 billion, and Humana is noting $5 billion. They have multiples of these amounts in long-term and short-term investments; they spend hundreds of billions on stock buybacks, dividends, and board and executive compensation. By digging into their assets, the cash rich health insurance business would be able to charge fair prices and stop their criminal behavior without much of a dent in a reasonable return on their investments.
In this Dark Age of Plutocracy, the Superrich & Corporations are Lying and Blaming Government & Ordinary Americans for Poor Healthcare and Excess Expenditures
“The growing elderly population is blamed for federal debt when Medicare and Social Security have little impact….”
Americans earning wages and salaries are being subjected to a corporate network of disinformation and gaslighting. President Biden is blamed for cutting Medicare when he is in fact attempting to protect the program. The growing elderly population is blamed for federal debt and deficits when Medicare and Social Security have little impact on the federal budget (SS has none and over half of MC is paid through payroll deductions, premiums, and co-pays). The nursing home industry blames taxpayers for failing to provide them with enough money to adequately care for the elderly and disabled patients in their beds while they spin a false hardship narrative.
The Medical-Industrial Complex has established a network of front groups with a duplicitous message of doing good for Americans and has enlisted the aid of do-gooder nonprofits, universities, and individuals. This system and its apparatchiks aren’t all that clever. Their organizational tactics are rather easy to discern. The problem is that it is happening stealthily behind the scenes in Washington, D.C. and the 50 state capitals. The media is ignoring it. We intend to expose it and encourage everyone we can to join us in that endeavor.
Thanks to Susie and Ivanka Talevski, Seven Supreme Court Justices, and Individuals and Organizations Filing Amicus Briefs, the Federal Nursing Home Rights Act Has Been Strongly Reinforced.
In a decision written by Justice Ketanji Brown Jackson and reported on Thursday, the U.S. Supreme Court held that unambiguous provisions of the Federal Nursing Home Rights Act (FNHRA) are enforceable by private individuals under Section 1983 of the Civil Rights Act of 1871 (H.H.C. of Marion County v. Talevska[1]). This is a big deal because it means that practices such as use of chemical restraints and arbitrary transfer are illegal and a cause for action in federal courts. Patients and their families cannot be restricted only to medical malpractice suits in state courts and/or to state administrative remedies.
Susie Talevski, an attorney, initially filed a suit in Federal District Court on behalf of her mother Ivanka after her father Gorgi Talevski was arbitrarily transferred to a facility an hour and a half from their home. The transfer occurred after the Talevski family consulted with outside physicians and hired a neurologist to evaluate the regimen of drugs administered to Mr. Talevski It appeared that his health deteriorated after the drug regimen was initiated and improved after six powerful psychotropic medications were terminated from the regimen.
In conversations with Susie and her colleagues in Indiana, I’ve learned that it is very difficult to navigate the Indiana tort liability laws and even make it into state courts with a suit against a nursing home. As in most states, awards for victims of medical malpractice are capped and not more than a hand slap in Indiana.
Furthermore, as most of us who advocate for nursing home patients know, there is no real remedy at the state level in most states for any type of redress when abuse and neglect occur. Administrative remedies through state agencies tend to end up in the “nothing to see here” file.
In the final analysis, patients and families have the best chance for redress in federal courts when nursing homes illegally violate rights granted by FNHRA. I applaud Susie’s courage in fighting this case all the way to Supreme Court. In agreement with H.H.C. of Marion County’s claim that she didn’t have standing to sue in federal court, the district court threw out her case. She appealed to the 7th Circuit, which overturned the decision of the district court. H.H.C. of Marion County appealed, and the Supreme Court granted certiorari.
H.H.C. of Marion County v. Talevski Should not be Below the Radar, but it is.
The Supreme Court voting rights decision and the indictment of former President Donald Trump grabbed all of the headlines. H.H.C. of Marion County v. Talevski seems to have escaped media notice. I hope this case is discussed widely and in depth by advocates and scholars. The back story and the legal implications of the case are far more extensive and complicated than I want to deal with in this brief blog post. Protection of the right to be free from chemical restraints and capricious behavior of nursing home providers should not be left to state tort law and/or the whim of state agencies, many of which have a propensity to protect the interests of the industry at the expense of patients and families. Certainly, Indiana has one of the most anti-consumer torts laws in the U.S.
It was shocking to read the argument of the U.S. Solicitor General on behalf of the provider (H.H.C. of Marion County) before the Supreme Court. She claimed that administrative channels at the state level were sufficient to insure FNHRA rights. This naivete on his part is one more example of how out of touch federal administrative agencies are in assuming that individuals are not in serious jeopardy of having their rights violated or ignored within individual states.
The ”Medicaid Unwinding:” An Orwellian Euphemism for Abject Cruelty & Profound Ignorance
Fortunately, the Talevski family, the 7th Circuit, and seven Supreme Court justices could see that individual civil rights granted to all U.S. citizens by Congress should be protected in the federal courts under the Civil Rights Act of 1871, Section 1983. The precedents for this case have pertained mostly to Medicaid rights in general.
During COVID, the Federal Matching Percentage (FMAP) for state Medicaid programs was increased by a hefty percentage for the purpose of preventing the administrative burden on Medicaid beneficiaries who are required to reapply each year and prove their eligibility for the program. As a condition for receiving the FMAP uplift, states could not unenroll individuals from the Medicaid program. The number of people receiving Medicaid benefits, i.e., had access to medical care, grew at a vast rate. That program ended on May 1st, and now the so-called unwinding, i.e., kicking people off, has resulted in a precipitous drop in enrollees.
“With weak state regulation of healthcare providers, it is likely that states will regularly violate the rights of U.S. residents to medical care.”
With weak state regulation of healthcare providers, it is likely that states will regularly violate the rights of U.S. residents to medical care. Especially in states with far-right wing legislatures, harassment of poor individuals and families needing medical care and other assistance is ordinary and ongoing. In Arkansas, a state that tried for a waiver from CMS to force Medicaid enrollees to undergo drug tests, the current governor, Sara Huckabee Sanders, has come up with “Arkansas Renew” as the Orwellian label for her unenrollment program.
All realms of human rights and civil rights are critically important if we are to retain a semblance of Democracy. Drugging and disappearing people into out of the way institutions is one of the most chilling and horrifying practices imaginable in any society. Certainly, it is characteristic of fascist, authoritarian governments. That it happens on behest of corporations attempting to optimize return for shareholders, executives, and other special interests, doesn’t make it any less odious.
The Heritage Foundation “Project 2025” is Taking Right Wing Extremism to a New Level
Last Updated: July 30, 2024 by David Kingsley, PhD Leave a Comment
Dave Kingsley
Make no Mistake about It, Project 2025 is Powerful, it is Well-Funded, and it is Religiously Extremist, Misogynistic, and White Supremacist.
Last August, this headline appeared in the Washington Times: “Recruiting is underway for Trump-like ‘wrecking ball’ to shrink government and fire federal workers”[1] The wrecking ball to which the article was referring is a cadre of extremist right-wing individuals who will, if Trump wins in November, see to it that their allies staff his administration. The powerful, anti-Democratic Heritage Foundation has initiated a movement dubbed “Project 2025,” – a network of Christian Nationalist, states’ rights’, anti-choice, school censorship, and anti-constitution organizations steeped in religious zealotry and as far out on the right of the political spectrum as any movement in U.S. history.
The Heritage Foundation is claiming that 100 organization on the hard right have signed onto their project in preparation for ending U.S. Constitutional government as we know it.[2] They are intent on scrapping the form of federalism intended by the framers and accepted by the American people as it has evolved since 1789. The list of organizations signing on includes Moms for Liberty, Turning Point USA, Hillsdale College, Liberty University, Susan B. Anthony Pro Life America, Dr. James Dobson Family Institute, Family Research Council, and other reactionary groups.
Most people who pay attention to politics have heard of at least one or more of these fanatical groups. Adherents of the Moms for Liberty have been running around censoring books in school libraries. They are allied with DeSantis’s project to undermine public education and replace it with a revisionist, false history and toxic religious indoctrination. Turning Point USA was formed and led by Charlie Kirk a rabid disseminator of disinformation and supporter of Donald Trump and his tripe about stolen elections, insurrectionists as patriots & hostages, and other dangerous nonsense. He has successfully organized chapters on at least 400 college campuses.
These types of anti-American organizations have moved from the unthinkable to the normal in the past few decades. Even more diabolical and violent groups are lurking in the shadows of this cabal. The violent, neo-Nazi Proud Boys and other Hitler sympathizing white male organizations are operating on the perimeter of the movement and tolerated at meetings of CPAC and Turning Point USA.[3]
Project 2025 is in Sync with the Ultra Conservative, Six Member Supreme Court Majority and the Republican Party
The current six-member majority on the U.S. Supreme court is acting not as jurists but rather as idealogues with sympathies for the dominant and dogmatic religious leaders of the Republican Party and a very mentally disturbed Donald Trump. Mainstream legal scholars are horrified by their actions and are speaking out about it[4] – to no avail. Not only is the overtly ideological majority on the court signaling that they will seriously weaken federal agencies,[5] they are expressing a considerable amount of sympathy for reducing women to second class status,[6] and interfering with privacy rights of gay and heterosexual married couples.[7]
It also appears that the S.C. majority has piled weight on the scales of justice for Donald Trump who is attempting to forestall his criminal trials by claiming total immunity for anything he did as president. This is an absurd claim rejected by a unanimous three judge panel of U.S. Court of Appeals for the District of Columbia Circuit. Nevertheless, the S.C. decided to hear the case and help stall justice for the American people who need a decision prior to the November 4th election.
Rarely in U.S history has the Supreme Court issued rulings that retract previously granted liberties. However, this court is intent on remaking law to reflect their favoritism toward a fundamentalist Christian theocracy with concentrated power in the hands of ultra-conservative white males.
What Project 2025 Means for the Elders of America
Like other vulnerable groups in American society, the elderly are falling prey to economic predators. This is consistently becoming a bigger problem, but it is happening without adequate federal regulation. This is particularly the case for elders institutionalized in “nursing homes.” Lax oversight of the nursing home industry prior to 2020 and the spread of COVID led to 2000 patient and 200 employee deaths. This was preventable and shouldn’t have happened. Nevertheless, the media, white-washing commissions, government agencies, and the legal system have displayed no propensity to hold the industry accountable for its neglect.
While the scourge was killing and isolating nursing home patients, the right-wing media and politicians and pundits appearing on their networks were claiming that masking, isolating, and preventative behaviors in general weren’t necessary because as Bill O’Reilly mused on Fox News: “The [U.S. death] projections that you just mentioned are down to 60,000, I don’t think it will be that high. 13,000 dead now in the USA. Many people who are dying, both here and around the world, were on their last legs anyway.”[8]
O’Reilly’s attitude reflects a far wider viewpoint about the value of older Americans than our government and politicians would care to admit – even beyond the confines of the radical right. However, the strength of an underlying theological dominionist[9], government-hating religiosity – combined with grievances against liberal, women, gay, ethnic, transgender, and other non-white male outgroups – does not bode well for programs such as Social Security, Medicare, and humane care for frail elders. Crazy religious views of the extreme right have incorporated a glorification of private corporations and privatization of government services. This is an outgrowth of their hatred of liberal programs from the New Deal forward and the political liberalism that era implies.
Summary
Religious fanatics want to run America. They have made significant inroads in doing just that (think school vouchers). The Christian extremist alliance with violent, neo-Nazi organizations is even more disturbing. Under the influence of the Heritage Foundation for the past fifty years and now its Project 2025, this coterie is infecting the mainstream of U.S. political discourse and jelling into a real threat to our constitutional form of government.
Coverage of right-wing fanaticism by the mainstream media has been problematic. The Heritage Foundation was formed by wealthy individuals on the far right in the 1970s. At the time, it was considered too radical for the normal American politically centered zeitgeist. By the 1980s, representatives of the organization were invited as guests on moderate news outlets such as PBS News Hour and it became a go to entity for print media seeking what they believed to be normal conservative views.
The MSM tends to engage in a misguided form of “fair and balanced” coverage of political groups with the chutzpa to push unthinkable views hard enough and long enough to become accepted into the Washington, D.C. establishment. The undeserved respect these entities receive inside the D.C. beltway – including by the press – creates a form of induced ambiguity in mass communication and voters’ thought processes. The real danger and odious facets of the Heritage Foundation and Project 2025 are minimized in leading new outlets out of respect for their success in becoming part of the normal political establishment.
I’m worried about the level of energy exerted by moderates in pushing back on the well-organized and aggressive organizations constituting Project 2025. Furthermore, there should be vocal opposition to the media myth about a “divided country” as if there are two equally legitimate sides in U.S. politics. In truth, American political views can be characterized as a broad, ambivalent middle with loud minorities on the fringes. The loudest and most effective fringe voice these days is on the right. Is it even fringe any longer?
[1] Lisa Mascaro – Associated Press – Tuesday, August 29, 2023, Recruiting is underway for Trump-like ‘wrecking ball’ to shrink government and fire federal workers – Washington Times
[2] Project 2025 Reaches 100 Coalition Partners, Continues to Grow in Preparation for Next President | The Heritage Foundation
[3]Nazis mingle openly at CPAC, spreading antisemitic conspiracy theories and finding allies (nbcnews.com). CPAC is the acronym for Conservative Political Action Committee. CPAC is the dominant and most persuasive voice of the Republican Party. Meetings of CPAC draw leading Republican U.S. Senators and Congresspersons as speakers. Donald Trump has been the keynote speaker at these gatherings since 2017. An NBC News story included this: “At the Young Republican mixer Friday evening, a group of Nazis who openly identified as national socialists mingled with mainstream conservative personalities, including some from Turning Point USA, and discussed “race science” and antisemitic conspiracy theories.” See also: Neo-Nazis gathered outside the Turning Point USA summit at Tampa Convention Center this weekend | Orlando | Orlando Weekly
[4] See, e.g.: The Public Has a Right to Trump’s Speedy Trial – The Atlantic; Stanford Law School’s Mark Lemley Argues the Supreme Court is Making an Unprecedented Power Grab – Legal Aggregate – Stanford Law School
[5] (See Loper Bright Enterprises v. Raimondo | Oyez; Discussed on this blog: Russia & the United States: Two Different Countries, Two Different Styles of Kleptocracy
[6] 19-1392 Dobbs v. Jackson Women’s Health Organization (06/24/2022) (supremecourt.gov)
[7] In Dobbs v. Jackson, Clarence Thomas expressed interest in overturning the right to contraceptives – a right granted in Griswold v. Connecticut, 381 U.S. 479 (1965) – and the right of gay people to marry, which was accorded in Obergefell v. Hodges, 576 U.S. 644 (2015).
[8] Bill O’Reilly says people who died from coronavirus ‘were on their last legs anyway’ (cleveland.com)
[9] Along with misogyny and white supremacy, Dominionism is one of the more perverse political philosophies driving the Christian Nationalist movement. Proponents of this weird and dangerous philosophy are increasingly successful in persuading the Republican Party to seriously consider and adopt their ideas. Dominion theology includes a belief in a Christian nation ruled on biblical tenets – whatever those may be. Many of the opponents of imaginary “woke education” would replace it with false teaching about the framers’ intent, which they claim was to create a “Christian Nation.”
Last Updated: April 5, 2024 by Kent Comfort Leave a Comment
Russia & the United States: Two Different Countries, Two Different Styles of Kleptocracy
By: David Kingsley
Stealing from Taxpayers is Kleptocratic Behavior in Any Government
After the collapse of the Soviet Union, Russia began to transition from totalitarian communism to an oligarchy of politically connected apparatchiks and mobsters from the Soviet era. The productive sectors of the economy such as oil and gas and manufacturing were looted in a crude takeover by a powerful criminal cabal including the KGB and high officials of the Communist Party. There was nothing subtle about it. The economy was dismantled and carried off by an in-group of thieves and criminal enterprises. The health and lifestyle of the Russian people dropped precipitously. There was no longer any pretense about an economy designed for the rise of the workers. That era was over and kleptocracy became de rigueur.[1]
“The kleptocratic facet of the current U.S. economic dark age is far more refined than the brutish nature of the Russian oligarchy.“
As Soviet Communism was failing, the United States was transitioning from a “golden age of capitalism” to a dark age of government regulatory retrenchment, Wall Street dominance, loss of faith in government for the general welfare, a sinking middle class, stagnant working-class wages, and deteriorating population health. The kleptocratic facet of the current U.S. economic dark age is far more refined than the brutish nature of the Russian oligarchy. The conditioning of the American people has been sophisticated and in most instances difficult to recognize.
The kleptocrats of Russia merely took what they wanted right out in the open. U.S. kleptocrats applied an abstruse intellectual justification for weakening government checks and balances, dismantling regulatory agencies, and privatizing government services. Mythical beliefs about a nonexistent free market were generated in leading universities and sold to legislators and the public. Hence, a thing no more real than a unicorn was concocted by academic economists and marketed as the ultimate decision maker. The idea of “the market” was reified into an entity – an entity has never been observed or measured – endowed by theorists with complete knowledge and the ability to make the best decision about how government should work vis a vis private industry.[2] Indeed, it has been working increasingly well for the rich and powerful.
A Kleptocrat by Any Other Name is Still a Kleptocrat: An Example
Peter G. Peterson: Multi-Billionaire Founder of Blackstone
The late multi-billionaire Peter G. Peterson along with Stephen Schwartzman, founded the Blackstone Group, a financial services conglomerate. Mr. Peterson dedicated a billion dollars to the privatization of Social Security and Medicare. The trillions of dollars expended by the SS Trust Fund and Medicare program make an inviting target for a vulture capitalist. Unfortunately, Peterson had a stellar reputation inside the Washington, D.C. beltway where cliques of corporate and individual wealth roam. His front groups such as the Committee for a Responsible Federal Budget (CRFB), the Concord Coalition, and the Peter G. Peterson Foundation, jelled into a highly influential network of “go to” organizations for public policy.
Maya MacGuinness, CEO of CRFB, is frequently the only person quoted when federal budgeting is covered in leading mainstream publications such as the New York Times. Her mantra is that Social Security and Medicare are leading causes of budget deficits. This is not true and she either knows that and is lying or she is seriously incompetent and ill informed. Either way, representatives of mainstream media – including PBS – are irresponsible for consulting her.
Medicare is undergoing rapid privatization, and an increasing amount of public funds are diverted from care to a bevy of private for-profit financial intermediaries. This has increased the cost of Medicare. But this increased expenditure is not devoted to better care. Rather it is siphoned off into shareholder earnings and benefits a few wealthy individuals.
Medicare wasn’t privatized solely under the influence of Peter G. Peterson. The Medicare Modernization Act of 2003 included Part D – a prescription drug benefit – and was pushed by Big Pharma. The insurance industry pushed the act because it included Part C – privatization of the entire program under what has become known as Medicare Advantage.
Social Security remains un-privatized and administered at a cost of ½ of 1 percent of revenue. Wall Street would love to privatize it in the same manner as Medicare and earn huge management fees that would rake off up to 25% of revenue, which has been the experience in the privatized Chile SS program.
Nursing Home Kleptocrats
“It is a shabby business carried out by sleazy businessmen in a weakly regulated government funded skilled nursing system.“
Investors have a vast interest in frail elderly and disabled Americans institutionalized in the disgraceful U.S. nursing home system. They can get by with a minimal, substandard, quality of care while extracting and pocketing optimal amounts of cash. It is a shabby business carried out by sleazy businessmen in a weakly regulated government funded skilled nursing system.
A richly funded propaganda machine and political contributions are responsible for a veil of secrecy around the corruption of an industry with little interest in optimal care of the people in their charge and from whom they are expropriating assets that would otherwise be passed to their heirs, thereby causing even more maldistribution of wealth. While tunnelling excess amounts of government provided revenue through subsidiaries and shell companies, they have effectuated a first-class propaganda machine that has sold lies about financial hardship and underfunding from government. I even see this lie promoted in peer reviewed journals – mostly from economists.
Propaganda works. The industry lobby has an effective PR campaign that leads the public to believe that it is tough to make money running nursing homes. They rely on the lack of financial literacy among most people by noting a general low operating margin reported by most facilities. These misleading statements regarding nursing home facility cost reports submitted to state regulators and CMS are often taken at face value by academics, the media, and advocates. Consequently, supposedly peer reviewed publications include findings from data dumps of information taken from facility-specific reports.
Right Wing Fanaticism Didn’t Shrink Government. However, It Did Shrink Democracy.
A well-known anti-government fanatic once said that he wanted to shrink government down to a size small enough that he could drag it into the bathroom and drown it in the toilet. Cute. Grover Nordquist is the guy we are talking about here. Although he is clearly an idiot, politicians have lived in mortal fear of his condemnation and avoided any hint that they might raise taxes – meaning individual and corporate taxes. Reaganites, Nordquististas, Paul-groupies (Ron and Rand) and indeed the libertarian extremist, government hating, right-wing of American politics believe that taxes feed “the beast.” So, they were successful in collapsing individual income tax brackets, lowering corporate income taxes, and devolving taxes to the states in the form of regressive sales, excise, and user taxes. At the same time, executive branch agencies with the purpose of protecting the public from corruption and abuse and implementing legislation have been weakened considerably.
“Along with privatization of government services – especially healthcare – a weakened regulatory system has been conducive to a refined form of looting….”
The middle- and lower-income classes are not paying lower taxes. Billionaires and corporations are. Furthermore, an increasing amount of middle- and lower-class income and wealth is being distributed to families and individuals with the highest level of income and wealth (think “spend downs” in nursing homes). Along with privatization of government services – especially healthcare – a weakened regulatory system has been conducive to a refined form of looting through Medicare, Affordable Care Act, Medicaid, Pentagon/defense budgeting, and a multitude of other forms of privatization. Well, maybe not so refined, if we just take a closer look at it.
Without a robust federal regulatory framework, the rights of Americans are now trampled by special interests who have been able to tilt the tax codes in their favor and takeover government services at costs higher than would be if the services were provided by federal agencies. One unfortunate result of this form of looting is that Americans are increasingly gouged by health insurers and paying more than their peers in Asia and Europe, but their overall health is worsening.
The U.S. Supreme Court is About to Seriously Dilute Executive Branch Regulatory Power
Federal laws can be sweeping and complex. The Clean Water Act, the Occupational Safety & Health Act, and the Medicare Modernization Act are examples of laws that have induced systemic change in U.S. government and society. These laws cannot anticipate, nor can they address every contingency in day-to-day implementation. Congress has traditionally considered technically qualified agency personnel to be responsible for filling in the “gaps” in highly complex legislation.
Industries affected by major legislative changes have typically fought administrative regulations issued by the EPA, OSHA, FDA, and a host of other regulatory agencies. They have attempted to blunt regulations through the courts, propaganda, and the political process. However, in the 1984 case Chevron USA, Inc v. The Natural Resources Defense Council, Inc., the Supreme Court enhanced the legitimacy and legality of agency regulations and strengthened Executive Branch oversight. The Court held that deference should be accorded to administrative agencies with the technical capability and scientific knowledge for addressing ambiguous issues in legislation.
That precedent is likely to be overturned when the Court hands down decisions on two cases already heard this session: Loper Bright Enterprises v. Raimondo and Relentless, Inc. v. Department of Commerce. The cases concern regulations issued by National Marine Fisheries Service (NMFS) under the Magnuson-Stevens Fishery Conservation and Management Act (MSA). The forthcoming decisions will address two major questions:
1. Should Chevron v. Natural Resources Defense Council be overruled?
2. Does statutory silence concerning controversial powers expressly but narrowly granted elsewhere in the statute constitute an ambiguity requiring deference to the agency?[3]
The six conservative idealogues on the court are expected to answer question 1 in the affirmative and question 2 in the negative. This is a particularly horrendous prospect for the U.S. healthcare system, which has outsourced trillions of dollars to some of the largest corporations in the United States. These corporate behemoths with very deep pockets or trade associations with vast resources will take their dislike of particular regulations into court and will often find friendly judges who will interpret regulations in their favor even though they – the judges – will have no scientific credentials to make technical decisions. This has already occurred in the Alliance for Hippocratic Medicine v. U.S. Food & Drug Administration[4], which was heard before the Supreme Court last week.
In that case, a federal judge in West Texas issued a ruling that overrides the scientific research undertaken by the FDA in the approval process for mifepristone (also known as “RU486” and “Mifepristone”) – more commonly called “an abortion pill.” The S.C. will no doubt find that there is no standing to sue on the part of the anti-abortion doctors. Nevertheless, the question of whether a judge can override reasonable regulations issued by the FDA will be left open. That is where this case intersects with the Chevron deference principle that will most likely be overturned.
This does not bode well for women’s reproductive rights specifically and for healthcare in the U.S. generally. As these court cases pertain to kleptocracy, a corporate friendly and extreme right-wing majority on the S.C. is in a position to neuter federal agencies and strengthen the hand of kleptocrats.
Summary
Acts of government sanctioned cheating and stealing from the American people are permeating the multi-trillion-dollar government funded healthcare system. As government funded medical care is increasingly privatized and corporations in the business become bigger and more powerful than the agencies regulating them, more funds will be diverted illegally from care into owners’ pockets. For instance, I’ve noticed an increasing number of nursing home facilities maltreating and underpaying employees, which discourages applicants for work and induces turnover. At the same time, they contract for labor from subsidiaries of their parent/holding companies at an extremely high rate. We have examples of facilities contracting with related parties for 50 to 63 percent of their labor. State and federal agencies have failed to even notice let alone deal with this egregiously illicit practice.
This example of labor contracting is only one of many, many forms of cheating. MCOs often deny authorization for physician prescribed treatment in their networks to keep their cost below capitation rates. Hiding and distorting information on cost reports, overcharging for services, upcoding therapy services, funneling funds through shell companies to hide excessive extraction of funds, and pressuring congress through bribes (campaign contributions) to unjustifiably increasing reimbursement, i.e., rent seeking are a few more examples of cheating and stealing. It should come as no surprise that the American people pay two to three times more per capita for healthcare than the people of our Asian and European peer countries with universal, single payer, government managed healthcare systems.
My purpose in writing this blog post is to encourage attention to psycholinguistics in advocacy, scholarship, and public discourse in general. Professionals and scholars are reticent about applying terms such as kleptocratic to behaviors that are best described as that. The media avoids harsh and condemnatory terminology – even when it called for in describing events and acts.
Stealing is stealing, thievery is thievery, whether they happen through a home/business break-in, or through cheating on forms submitted to the federal and state governments. White collar crime is unfortunately placed on a higher plane and is less punishable than street crime generally committed by the poor and powerless members of society. How we describe behaviors and what we call them has significant influence on how they are perceived and treated in political discourse and the criminal justice system.
[1] Terms such as plutocracy, oligarchy, and kleptocracy are not mere words and are not used in this blog for name calling. In public discourse words should be taken seriously and utilized in a technically correct manner as scholars in political philosophy would theoretically utilize them.. Kleptocracy is defined as: “ a form of government by individuals who primarily seek personal gain at the expense of those they govern.” Kleptocracy | Definition, Examples, Kleptocratic Leaders, Dekleptification, & Facts | Britannica.” Given this broad definition of kleptocratic behavior, examples of it abound in the U.S. and are manifested even more crudely in Russia. Terms such as oligarchy, plutocracy, and kleptocracy can all apply to any one government in any one nation state. Oligarchy pertains to rule by a small number of individuals sans democracy. Plutocracy is rule by the wealthy – also contrary to democratic governance. As wealth is distributed away from the masses to a small number of superrich individuals, plutocracy is intensified and becomes more salient in political processes. Hence, the system becomes more oligarchic because the power is posited in a smaller number of individuals. The intersectionality of plutocracy and oligarchy is of importance in this discussion. Furthermore, the correlative increase of rule by the few in their private interest, contrary to the public interest, and the concentration of wealth in a tiny minority leads to corruption on a wide scale. Therefore, resources that could be dedicated to elevating the health and lifestyle of the masses are diverted to a wealthy few. For instance, government tax receipts flowing from wage and salary earners have been increasingly and excessively diverted to shareholders at the expense of government services intended to improve the health and welfare of all classes of U.S. residents. Kleptocratic behavior is expressed in the healthcare system by the proliferating number of financial intermediaries such as insurance companies, pharmacy benefit managers, etc. who drain resources from care without adding effectiveness and efficiency to the overall system.
[2] Reification is a frequent fallacy in pseudoscientific thought processes. Naming and describing something abstractly do not prove that the thing exists concretely. The free market as an abstraction is a description of trillions of daily interactions in which people buy and sell things. It is fallacious to call all of those interactions a thing.
[3] Relentless, Inc. v. Department of Commerce | Oyez
[4] AllianceForHippocraticMedicineComplaint.pdf (windows.net)
PBMs, The Invisible $500 Billion Per Year Industry
Last Updated: July 30, 2024 by Kent Comfort Leave a Comment
By: Kent Comfort
Anyone who has a regular medication regimen is usually quick to lament how costly it is. Well, you know, drugs are expensive, especially in America! But, what is the industry structure that determines and manages the price? The answer is found in a middleman enterprise known as the PBM, an acronym for Pharmacy Benefit Management. This acronym can also double as an oxymoron for patients who need medications because they are not benefiting from this interference in the system. Profit By Middlemen might be a more honest label.
“Profit By Middlemen by might be a more accurate explanation”
Most Americans have no awareness of the methods used to control and manage the cost of drugs they are prescribed. Their normal routine is to inform their doctor what pharmacy locations they visit to acquire their medications. And that is where their knowledge of the pharma industry ecosystem stops. Their doctor calls in the script, and they just drop by to pick it up. The process in the past of being handed a piece of paper from a prescription pad with a scribbled signature is long behind us.
PBM definition
The definition of PBMs can vary greatly depending on the source. It is by any measure a controversial element of the Medical-Industrial Complex. Industry advocates will claim without a means of proof that the purpose of a PBM is to reduce the cost of medications to insurance companies, that ultimately passes through to patients. That may have been the original intention and purpose, but there is no visible transparency that can clearly verify that fact. PBMs are middleman businesses that opaquely work both ends against the center. Study the graphic at the end of this article.
“PBMs are middleman businesses that opaquely work both ends against the center..”
In essence, their role is to negotiate drug pricing directly with the pharmaceutical manufacturer. They have contracts with the giants in the insurance industry who hire them to perform this task, and that gives PBMs considerable pricing leverage with the pharma manufacturers.
Do PBMs Actually Benefit Patients?
Theoretically, this service would lower the final cost to the patient. But as it turns out, it often causes price increases to that patient. The PBM earns money by charging their customer, the insurance company, a fee. They also mark up the cost they negotiate for the drugs to create a margin that results in additional income. To the tune of $500 billion per year. There is no transparency in this process. I will share more about that later in this article.
Origin and History
PBMs first came on the medical industry scene in 1968, but they were not called that initially. The first iteration was called the Pharmaceutical Card System. United Healthcare was involved from the start, and therein lies one of the problems with this concept. The clear conflict of interest is a major and unavoidable factor. And it has proven to be obscenely profitable for them.
Today, due to a continuous progression of industry consolidation there are three giants in this space that control about 80% of the total PBM market. They are Caremark owned by CVS, OptumRX owned by United Healthcare, and Express Scripts owned by Medco Health Solutions.
The MIDDLEMAN issue
It is often not wise to trust any middleman source on the surface. There may be instances and examples in business that prove middlemen to be beneficial. But more often than not, it is usually a rent-seeking enterprise that results in elevating the cost of a service or product to the end user.
“There is no sufficient way to verify if savings are realized by the customer…”
There is no sufficient way to verify if savings of any consequence are passed on to the final consumer. An industry lobbying organization claims that roughly $43 billion per year will be saved by the PBM business model over the next ten years. Even if that can be proven, earnings of $500 billion per year only yielding ten percent in cost reduction is not an impressive ratio.
Transparency, as in not any…
The PBM industry has attracted much controversy, leading to a substantial volume of litigation due for the most part to the opaqueness of the business model. PBMs demand pharmaceutical manufacturers and pharmacies keep their cost amounts confidential. The margins PBMs realize in their pricing structure are closely held secrets. PBMs also do not permit pharmacies to recommend lower cost alternatives unless they are specifically asked to do so by their customers. The margins are much more profitable for the PBMs when the drugs are higher priced.
“The margins PBMs realize in their pricing structure are closely held secrets…”
Another contentious factor between PBMs and pharmacies relates to control of dispensing fees. It is dictated to pharmacies what they can add to the cost of filling a prescription. PBMs have seemingly captured too much control over the entire industry that has resulted in higher costs rather than savings passed on to the end user.
A Voice From Behind the Pharmacy Counter
I questioned a friend who has been a practicing pharmacist for several decades. He has seen a vast alteration of the pharmacy landscape during his years in the business. Moreover, his father was also a pharmacist who practiced for 50 years, and owned drugstores in multiple towns, back when that was definitive of what they were. His experience spans a variety of pharma business verticals, from independent pharmacies to national corporate chain stores, clinical pharmacies within hospitals, and managing clinical trials. During his career, he has seen and experienced the full spectrum of the pharmaceutical ecosystem. He had a lot to say about PBMs and their unwelcome effects.
Some examples include; a lack of transparency, rebate practices, spread pricing, limited pharmacy networks, high out-of-pocket costs for some patients, the Impact on independent pharmacies (low reimbursement rates and restrictive networks), and some PBMs are vertically integrated with health insurers or pharmacy chains, which can create potential conflicts of interest and reduce competition in the market.
Pharmacies acquired their inventories before the advent of PBMs either through major distribution channels that served as the original intermediaries between the manufacturer and the drugstore, or directly from the manufacturer. There were, and still are, pharmacists who are skilled in compounding medications. You can probably find one in your area if you search carefully enough. Compounding pharmacists create personalized medications by combining, mixing, or altering ingredients to meet the specific requirements of a patient’s medical condition, age, weight, allergies, or other factors.
Many aspects of practicing pharmacy changed when PBMs seized control of these earlier business methods, and not in a positive manner. A formulary today is not what it was decades ago. The PBM dictates what the formulary is today. The remuneration aspect of formularies, according to my friend, can absolutely and negatively impact the profitability of the business in a number of ways. It explains why a drugstore today is more like a minimart where the customer can also buy a gallon of milk, a quart of motor oil, and even toy wagon for a child. How about that candy aisle? There’s some health-conscious products for you!
About that income from filling a prescription? A medication costing $50.00 versus one that costs $500.00 results in virtually no difference in earnings for the pharmacy. The only difference is the burden of maintaining inventory. The margins are captured and controlled by the PBM, not the business where drugs are dispensed.
Patient Stories
What about from the patient perspective? Buying a prescription is a minefield today. It can feel like being a con man’s mark in far too many cases. But fortunately, conscientious pharmacists are siding with the patients more every day. Since pharmacists behind the counter are discouraged by PBMs from advising the customer regarding more economical alternatives to what has been prescribed, they have found ways to help the medication customer save money. One example is to provide a discount card they have on hand for the customer’s benefit.
“Customers are learning not to accept the first price they are given…”
Medication customers are learning not to accept the first price they are quoted. They are finding more affordable options by asking the pharmacist if a generic version is available. Pharmacists are instructed by PBMs not to volunteer that information, but to provide it when asked. People are also searching online for lower cost options when beginning the regimen does not require urgency or expediency.
I was recently told a story by a friend who diligently explored every option available and was able to reduce an initially quoted price of $50.00 down to $2.00. That is an extreme example, but it reveals the benefit of making the effort whenever possible.
Alternatives and Solutions
When the balance between efforts to monopolize any business sector and the customer base being served becomes too lopsided, it inevitably opens the door for disruption and new competition. Two present day disruptors to emerge are Mark Cuban Cost Plus Drugs, and Amazon Pharmacy. Mark Cuban aggressively negotiates with drug manufacturers and then adds 15% to the cost. This can result in remarkable savings in some cases. Amazon Pharmacy is accomplishing the same outcome due to the leverage they can exercise because of the size of their existing customer base.
It is highly likely there will be imitators entering the market in large numbers as they watch these two sources capture more and more market share over time. Also, it has been common practice for years for American pharmaceutical consumers to order their drugs from Canadian and Mexican sources when possible.
Study this innocuous appearing graphic carefully. When you read it closely, you may feel it obfuscates as much or more than it clarifies. Nevertheless, you can see the power PBMs have over the industry because they embed their business process into the most critical touch-points in the retail drug eco-system.
Posted: March 18, 2024 by David Kingsley, PhD Leave a Comment
How the Health Insurance Industry is Using Disinformation to Take Over and Defraud Medicare
By: Dave Kingsley
Corporate Greed in the Post-Truth Age
Most Americans have never heard of the Better Medicare Alliance[1] – a Washington, D.C. think tank and front group for big health insurers such as UnitedHealth, Aetna, and Humana. Also, the 2023 Super Bowl TV audience didn’t know who paid for a commercial at halftime claiming that President Biden had plans to “cut Medicare.” The ad included a message urging viewers to call the White House and “tell President Biden not to cut Medicare,”[2] but they – the TV viewers – didn’t know who was asking them to do it. Football fans had to be perplexed. Medicare beneficiaries were most likely upset and worried by what they saw and heard.
“One illegal practice health insurers utilize to add unearned value to their Medicare Advantage (MA) reimbursement is called “upcoding.”
The ad, funded by Better Medicare Alliance, was a lie. The truth is that President Biden had no intention and no plan to cut Medicare. Contrary to what the ad claimed, he was planning to claw back $4.7 billion from UnitedHealth and other insurers for defrauding the program through false billing practices. One illegal practice health insurers utilize to add unearned value to their Medicare Advantage (MA) reimbursement is called “upcoding.” Because sicker patients are reimbursed at a higher rate, the trick is to find ways to lie about how sick a patient is – to make them look sicker than they are.[3]
MA beneficiaries tend to be healthier than Traditional Medicare (TM) beneficiaries. Nevertheless, research indicates that when individuals move from TM to MA, their costs to the program increase. The important point is that “total Medicare payments to MA plans in 2024 (including rebates that finance extra benefits) are projected to be $83 billion higher than if MA enrollees were enrolled in FFS Medicare.” Furthermore, payments to MA plans average an estimated 122 percent of what Medicare would have expected to spend on MA enrollees if they were in FFS Medicare.”[4]
After the Biden Administration’s proposal to recoup stolen money from MA insurers and prevent further fraud, the health insurance industry threw a conniption fit and went into overdrive. The Super Bowl ad was only one tactic (costing eight figures, it was super expensive). In addition, they sent their army of lobbyists crawling all over the Washington, D.C. beltway threatening and bribing legislators. HHS backed down. The cheating continues and costs the seniors of America – indeed all wage earners – hundreds of billions from their payroll deductions, premiums, co-pays, and nearly $200 out of every Social Security check.
Pulling Back the Curtain on the Washington D.C. Policy Planning Network: What is the Better Medicare Alliance & Who is Behind It?
The insidious thing about think tanks set up inside the Washington, D.C. beltway is that they enlist the aid of seemingly legitimate advocates and scholars. It is hard to know if the advocates and scholars are merely naïve or whether they are self-serving. Perhaps unwitting would be a kinder word. For instance, the Better Medicare Alliance board consists of Dennis Borel, Executive Director of Texans with Disabilities, Caroline Coats, Humana, Inc., Daniel Dawes, Meharry Medical College, Mary Beth Dawes, Former Congresswoman (President & CEO), Joneigh Kaldhun, CVS Health, Dan Lowenstein, Visiting Nurse Service, NY, Richard Migliori, UnitedHealth, Elena Rios, National Hispanic Medical Association, and Kenneth Thorpe, Emory University.
The organizational structure of these industry front groups is a form of disinformation itself. On the board are big players in the MA industry – Humana, CVS, and UnitedHealth. Interspersed with the representatives of these health insurance behemoths are executives and professionals from organizations with an ostensible mission to improve society in some manner.
By placing their imprimatur on an industry lobbying group, NGOs, nonprofits with a stated humanitarian cause, and universities are participating in a duplicitous tactic to confuse the public about the real purpose of nefarious industry think tanks like Better Medicare Alliance. Their support for various entities with a mission to preserve and strengthen the medical-industrial complex helps divert funds needed for care into the coffers of executives and shareholders.
Privatizing Medicare was Supposed to Reduce Costs and Give Beneficiaries More Choice: It Hasn’t Worked Out that Way.
MA is a creature of the Medicare Modernization Act of 2003. The right-wing of American politics accomplished a coup by setting Medicare on the road to privatization. Currently over 50% of all beneficiaries have selected it over Traditional Medicare ™. Federal policy is unfortunately driving Seniors into MA by allowing manipulative practices such as low premiums and a few benefits not available to TA beneficiaries. Seniors are being led like lemmings into the arms of the insurance industry by disinformation and deceit. Organizations like the AARP in partnership with health insurers like UnitedHealth are the Pied Pipers.
MA is one of the most serious threats to the health and well-being of American seniors. It robs money from care and transfers it into the pockets of investors and executives. Many beneficiaries are happy with low premiums and add-ons not available under traditional Medicare such as Silver Sneakers plus some dental and vision care. I can understand why many people who have it are pleased with their coverage. It works for healthier beneficiaries until it doesn’t.
If MA beneficiaries should incur a costly service that is not in network, their assets could be wiped out. Some retirees have no choice in the matter. If their company or institution includes health insurance as a retirement benefit, it is most likely MA. Furthermore, I can’t blame anyone who is trying to avoid the premiums for supplemental coverage under traditional Medicare. Avoiding bankruptcy and depletion of assets through a catastrophic sickness makes perfect sense for TA beneficiaries. But the supplemental insurance is a heavy burden that could be avoided if the Medicare program weren’t diverting so much funding to MA (see discussion below).
Seniors and People with Disabilities Would not be Struggling as Much If Big Health Insurance were not Stealing from Them.
For seniors and disabled Americans to lose nearly $200 per month of their Social Security and choose between a large payout for supplemental or the risk of bankruptcy, is an injustice when privatized healthcare is stealing hundreds of billions of Americans’ tax dollars, payroll deductions, and hard-earned money through out-of-pocket expenses. The Physicians for a National Health Program (PNHP) has estimated that MA overcharged taxpayers by a minimum of 22% or $88 billion and potentially up to 35% for a total of $131 billion in 2022. If the high end of the estimate were correct, all of Part B premiums ($131 billion in 2022) or Part D premiums ($126 billion in 2022) could be covered by excessive corporate extraction of funds from Medicare.[5]
UnitedHealth is noting $25 billion in cash and cash equivalents on its 2023 balance sheet, CVS has noted $12 billion, and Humana is noting $5 billion. They have multiples of these amounts in long-term and short-term investments; they spend hundreds of billions on stock buybacks, dividends, and board and executive compensation. By digging into their assets, the cash rich health insurance business would be able to charge fair prices and stop their criminal behavior without much of a dent in a reasonable return on their investments.
In this Dark Age of Plutocracy, the Superrich & Corporations are Lying and Blaming Government & Ordinary Americans for Poor Healthcare and Excess Expenditures
“The growing elderly population is blamed for federal debt when Medicare and Social Security have little impact….”
Americans earning wages and salaries are being subjected to a corporate network of disinformation and gaslighting. President Biden is blamed for cutting Medicare when he is in fact attempting to protect the program. The growing elderly population is blamed for federal debt and deficits when Medicare and Social Security have little impact on the federal budget (SS has none and over half of MC is paid through payroll deductions, premiums, and co-pays). The nursing home industry blames taxpayers for failing to provide them with enough money to adequately care for the elderly and disabled patients in their beds while they spin a false hardship narrative.
The Medical-Industrial Complex has established a network of front groups with a duplicitous message of doing good for Americans and has enlisted the aid of do-gooder nonprofits, universities, and individuals. This system and its apparatchiks aren’t all that clever. Their organizational tactics are rather easy to discern. The problem is that it is happening stealthily behind the scenes in Washington, D.C. and the 50 state capitals. The media is ignoring it. We intend to expose it and encourage everyone we can to join us in that endeavor.
[1] https://bettermedicarealliance.org/ [2] You can see the ad here: https://www.ispot.tv/ad/2UHG/better-medicare-alliance-cutting-medicare-thats-nuts. [3] Reed Abelson & Margot Sanger-Katz (2023), “Biden Plan to Cut Billions in Medicaid Fraud Ignites Lobbying Frenzy,” https://w.w.w.nytimes.com/2023/03/22/health/medicare-insurance-fraud.html?searchResultPosition=1. [4] Medicare Payment Advisory Commission (MDPAC), 2024, p. March 2024 Report to the Congress: Medicare Payment Policy – MedPAC [5] Physicians for a National Health Program, (2023), Our Payments their Profits: Quantifying Overpayments in the Medicare Advantage Program. MA Overpayment Report (pnhp.org)Last Updated: March 19, 2024 by David Kingsley, PhD Leave a Comment
DECISION: THE SUPREME COURT HANDS NURSING HOME PATIENTS AND THEIR FAMILIES A MAGNIFICENT HUMAN RIGHTS VICTORY!
BY: Dave Kingsley
Thanks to Susie and Ivanka Talevski, Seven Supreme Court Justices, and Individuals and Organizations Filing Amicus Briefs, the Federal Nursing Home Rights Act Has Been Strongly Reinforced.
In a decision written by Justice Ketanji Brown Jackson and reported on Thursday, the U.S. Supreme Court held that unambiguous provisions of the Federal Nursing Home Rights Act (FNHRA) are enforceable by private individuals under Section 1983 of the Civil Rights Act of 1871 (H.H.C. of Marion County v. Talevska[1]). This is a big deal because it means that practices such as use of chemical restraints and arbitrary transfer are illegal and a cause for action in federal courts. Patients and their families cannot be restricted only to medical malpractice suits in state courts and/or to state administrative remedies.
Susie Talevski, an attorney, initially filed a suit in Federal District Court on behalf of her mother Ivanka after her father Gorgi Talevski was arbitrarily transferred to a facility an hour and a half from their home. The transfer occurred after the Talevski family consulted with outside physicians and hired a neurologist to evaluate the regimen of drugs administered to Mr. Talevski It appeared that his health deteriorated after the drug regimen was initiated and improved after six powerful psychotropic medications were terminated from the regimen.
In conversations with Susie and her colleagues in Indiana, I’ve learned that it is very difficult to navigate the Indiana tort liability laws and even make it into state courts with a suit against a nursing home. As in most states, awards for victims of medical malpractice are capped and not more than a hand slap in Indiana.
Furthermore, as most of us who advocate for nursing home patients know, there is no real remedy at the state level in most states for any type of redress when abuse and neglect occur. Administrative remedies through state agencies tend to end up in the “nothing to see here” file.
In the final analysis, patients and families have the best chance for redress in federal courts when nursing homes illegally violate rights granted by FNHRA. I applaud Susie’s courage in fighting this case all the way to Supreme Court. In agreement with H.H.C. of Marion County’s claim that she didn’t have standing to sue in federal court, the district court threw out her case. She appealed to the 7th Circuit, which overturned the decision of the district court. H.H.C. of Marion County appealed, and the Supreme Court granted certiorari.
H.H.C. of Marion County v. Talevski Should not be Below the Radar, but it is.
The Supreme Court voting rights decision and the indictment of former President Donald Trump grabbed all of the headlines. H.H.C. of Marion County v. Talevski seems to have escaped media notice. I hope this case is discussed widely and in depth by advocates and scholars. The back story and the legal implications of the case are far more extensive and complicated than I want to deal with in this brief blog post. Protection of the right to be free from chemical restraints and capricious behavior of nursing home providers should not be left to state tort law and/or the whim of state agencies, many of which have a propensity to protect the interests of the industry at the expense of patients and families. Certainly, Indiana has one of the most anti-consumer torts laws in the U.S.
It was shocking to read the argument of the U.S. Solicitor General on behalf of the provider (H.H.C. of Marion County) before the Supreme Court. She claimed that administrative channels at the state level were sufficient to insure FNHRA rights. This naivete on his part is one more example of how out of touch federal administrative agencies are in assuming that individuals are not in serious jeopardy of having their rights violated or ignored within individual states.
The ”Medicaid Unwinding:” An Orwellian Euphemism for Abject Cruelty & Profound Ignorance
Fortunately, the Talevski family, the 7th Circuit, and seven Supreme Court justices could see that individual civil rights granted to all U.S. citizens by Congress should be protected in the federal courts under the Civil Rights Act of 1871, Section 1983. The precedents for this case have pertained mostly to Medicaid rights in general.
During COVID, the Federal Matching Percentage (FMAP) for state Medicaid programs was increased by a hefty percentage for the purpose of preventing the administrative burden on Medicaid beneficiaries who are required to reapply each year and prove their eligibility for the program. As a condition for receiving the FMAP uplift, states could not unenroll individuals from the Medicaid program. The number of people receiving Medicaid benefits, i.e., had access to medical care, grew at a vast rate. That program ended on May 1st, and now the so-called unwinding, i.e., kicking people off, has resulted in a precipitous drop in enrollees.
“With weak state regulation of healthcare providers, it is likely that states will regularly violate the rights of U.S. residents to medical care.”
With weak state regulation of healthcare providers, it is likely that states will regularly violate the rights of U.S. residents to medical care. Especially in states with far-right wing legislatures, harassment of poor individuals and families needing medical care and other assistance is ordinary and ongoing. In Arkansas, a state that tried for a waiver from CMS to force Medicaid enrollees to undergo drug tests, the current governor, Sara Huckabee Sanders, has come up with “Arkansas Renew” as the Orwellian label for her unenrollment program.
All realms of human rights and civil rights are critically important if we are to retain a semblance of Democracy. Drugging and disappearing people into out of the way institutions is one of the most chilling and horrifying practices imaginable in any society. Certainly, it is characteristic of fascist, authoritarian governments. That it happens on behest of corporations attempting to optimize return for shareholders, executives, and other special interests, doesn’t make it any less odious.