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Medicare Under Threat
The Full Story

Medicare Advantage programs have defrauded the Medicare Program of billions of dollars, money taken out of patient care funding. Private equity funds have their teeth in health care as of January 2023. Allowed to continue, the Medicare Trust Fund will be depleted by 2028, and for profit insurance, hospitals, and investor groups intend to destroy Medicare by 2030. (See PNHP.org)

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"We cannot solve our problems with the same thinking we used when we created them." Albert Einstein

  • Patient sees physician

  • Physician submits claim to Medicare

  • Medicare remits to physician

Traditional Medicare

President Lyndon B. Johnson signed Medicare into law in 1965. Since then Americans have looked forward to turning 65 and gaining medical care under this program. It is a simple one. American pay for the program through federal income taxes. Patients seek medical care from any doctor or hospital in the country; doctors claim payment for that care from Medicare; Medicare pays the doctor from a fee schedule. Over time Medicare saw many changes to this simple structure.

Starting in the 1970s, Medicare beneficiaries could receive managed care through private insurance companies. In 1997, that program became official with the passing of the Balanced Budget Act. In 2003, Medicare Part D was created and managed care was renamed Medicare Advantage plans. Companies argued that introducing competition between for-profit companies would lower costs and provide better care. That has proved untrue.

With the passage of the 2010 Affordable Care Act Medicare started paying insurance companies according to the risk associated with each patient. Medicare Advantage plans have manipulated that risk to bilk Medicare out of billions of dollars.

Two decades later, almost half of all seniors are enrolled in Advantage Plans instead of Traditional Medicare, the insurance companies are the most profitable in the country, and our country has the worst outcomes of any nation. Currently, those companies are charged with defrauding Medicare out of between $9 and $25 billion, and also with misleading and deceptive advertising.

  • Medicare subsidizes to Advantage plans

    • 85% must go to patient care

    • 15% pays CEOs, advertising, marketing, etc.

  • But, subsidy is based on insurance assessment of each beneficiaries risk

  • Medicare pays according to that "risk score"

  • Medicare Advantage plans are defrauding Medicare by "upcoding" conditions to increase "risk score" and increase subsidies.

  • Patients care is harmed

    • Patients locked into network doctors and services

    • Complex for patients

    • Necessary care often denied because of expense

  • Plans being investigated

Enter Medicare Advantage

January 2023, Enter ACO/Reach

  • Patients "aligned" into a ACE/Reach if their physician is "aligned" without adequate notice

  • Unclear whether physicians can opt out if their group or hospital adopts ACO/Reach

  • Where will the 40% profit be derived from?

  • How will patient care be affected?

ACO/Reach is fully implemented effectively January 2023. Wall Street investors see promise of huge profits. They can invest in any health related company including physician groups and hospitals who enroll as an ACO/Reach entity. ACO/Reach entities must direct 60% of Medicare payments to patient care; remaining 40% is profit. Private equity firms rarely stay invested in a company after they reach their profit goals.

Fully Privatized

  • By 2028 the Medicare Trust Fund will be bankrupt

  • For-profit entity goal: Eliminate Medicare by 2030

  • Health care professionals will be corporate employees subject to corporate policies

  • How will that affect the physician/patient relationship

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