14. Subsection: Centers For Medicare and Medicaid Services (CMS) pg 462-470

Project 2025 link: Centers For Medicare and Medicaid Services (CMS)

On Insurance

Turn Medicare into a free market program
Make people pay for some care under Medicaid
Put lifetime caps on Medicaid benefits
Their Affordable Care Plan is really just insurance of the bad old days, where they could charge you more based on your age and pre-existing conditions, sell you useless policies, in a new wrapper.
Dump the “No more Surprises” legislation that protects patients from large bills.
Based on their previous bill to overturn the ACA,
- they will let employers with more that 50 employees dump them into the open market.
- They would ban women from using government money to buy plans that covers abortion and ends non-abortion Medicaid reimbursement to Planned Parenthood.
- endorse maximum-limit caps on services.

Shareable videos! (https://www.youtube.com/watch?v=e9ibcIeBWPc&t=18s)

We in Ventura County are very fortunate to have a very active chapter of the Physicians for a National Health Program, which we can tap for their expertise in issues like this. This post has been annotated by member Dr. Leslie-Lynn Pawson.

Project 2025 is almost 900 pages of what the GOP wants you to believe. Here, they’ve shown what they will actually do.

Just in from the White House (March 26, 2024) (Link)

The budget from the Republican Study Committee—which represents 100% of House Republican leadership and 80% of House Republicans—would:

Slash $4.5 trillion from the Affordable Care Act, Medicaid, and the Children’s Health Insurance Program. These devastating cuts would take health care away from millions of Americans.
Ripping away coverage for more than 45 million people enrolled in ACA coverage and Medicaid expansion. The Republican budget completely strips funding from the Affordable Care Act’s Marketplace and Medicaid expansion—programs that cover 45 million people.
Turning Medicaid into block grants that would threaten coverage and care for an additional over 60 million Americans with Medicaid. States would be forced to make it harder to qualify and enroll in coverage, cut critical benefits, or both, threatening coverage for millions of children and families.
Threatening care for seniors and people with disabilities. Over seven million seniors and people with disabilities relying on Medicaid home care services could see it cut or taken away altogether, with ballooning wait lists for those who still need care. Hundreds of thousands of nursing home residents would be at risk of lower quality care if Medicaid had to cut nursing home payments.
Eliminate critical consumer protections. Millions of consumers are protected from insurance company abuses by the ACA, but the Republican budget sides with insurance companies to roll back these critical protections.
Over 100 million people with pre-existing conditions could be denied or charged more for coverage.
Older adults could face higher premiums. Health insurance premiums would skyrocket, especially for people in their 50s and 60s.
Insurance companies would be allowed to rip off Americans with junk insurance products. The Republican budget promotes the sale of junk insurance products, which can scam consumers and leave on them on the hook for tens of thousands of dollars in expenses.
Slash Medicare by turning it into a “premium support” program. In contrast with the President’s plan to protect and strengthen Medicare by lowering drug prices and making the wealthy pay their fair share, the House Republican budget would convert Medicare to a “premium support” program that would raise premiums for millions of seniors.
Raise prescription drug prices for seniors and give massive handouts to Big Pharma. The Republican Budget would side with Big Pharma to increase drug prices and seniors’ out-of-pocket costs by repealing the Inflation Reduction Act.
Medicare would no longer be able to negotiate lower drug prices.Big Pharma would once again be allowed to set whatever price they want, leaving seniors and taxpayers on the hook and facing higher prices.
Big Pharma would no longer pay Medicare back when they increase drug prices faster than inflation, allowing them to jack up prices with no accountability.
Seniors would go back to paying up to $400 for insulin, instead of the $35 price cap per monthly insulin prescription they have today.
Seniors would face higher costs if the $2,000 out-of-pocket cap on drug costs is eliminated.

If Republican elected officials get their way, these proposals would become the law of the land and Americans would pay the price.

MEDICARE ADVANTAGE PATIENT WARNING:

“Although originally an appendage to the traditional Medicare program, Medicare Advantage now can be more accurately described as the cannibalization of public health insurance by private firms. Despite routinely overcharging for services through billing code manipulation, these plans regularly deny care to those on them. This ultimately leads to worse health outcomes for Medicare Advantage beneficiaries, especially those of color.”

MEDICARE

Project 2025: Medicare: Medicare should be reformed according to four goals and principles

(Pg. 463) Increase Medicare beneficiaries’ control of their health care. Patients are best positioned to determine the value of health care services, working with their health care providers. They also benefit from increased choice of doctors, hospitals, and insurance plans. Access to reliable information with respect to physicians, hospitals, and insurers is therefore essential.

Response: Patients with Traditional Medicare have the maximum freedom of choice of doctors and hospitals. Medicare “Advantage” and ACO REACH plans in Medicare have restrictive networks that decrease beneficiaries’ choice. On average MA plans have 46% of physicians in a county in their networks with specialty and surgery coverage lower than that average. LESS CHOICE NOT INCREASED CHOICE.

(Pg 463) Reduce regulatory burdens on doctors. Doctors must be free to focus on treating patients first, not entering codes on computers, and should not be tempted to change their medical judgment based on arbitrary or illogical reimbursement incentives.

Response: It is profiteering insurance company managed Medicare “Advantage” that incentivizes physicians to UPCODE and promotes entering codes on computers and spending less time with patients. Patients in MA are given a risk score related to their diagnosed conditions, which is used as a multiplier for the amount of money Medicare capitates to the MA insurer to manage their care. The more diagnosed conditions and the more severe each condition that appears on a patient’s chart, the more money the insurer will receive from Medicare, creating an incentive for insurers to add diagnoses or inflate their severity regardless of their relevance or current status. This diagnosis-based risk adjustment formula, creates the opportunity to profit from upcoding. When providers are paid via Fee -For-Service (FFS )as in Traditional Medicare, there is no need for risk adjustment or tying payment to diagnosis, and thus no ability to profit from upcoding. The magnitude of difference between the risk score of patients in MA and Traditional Medicare is astounding. In 2019, the average risk score in MA was 20% higher than it would have been for the same patients in Traditional Medicare. According to Medicare Payment Advisory Commission (MedPAC), an independent agency created to advise Congress on the Medicare Program, the cumulative effect of this difference in risk scores accounted for $17 billion in excess payments to MA in 2021, which is close to 5% of total payments for that year. As a percentage of MA spending in 2022, this would be about $20 billion.

(Pg 463) Ensure sustainability and value for beneficiaries and taxpayers

Prices are best for patients when determined by economic value rather than political power and when they are known in advance of the receipt of services. Government’s use of non-market-based methods to determine reimbursement leads to overspending on low-value services and products and underpayment for high-value services and products, stifles beneficial innovation, and because of Medicare’s size distorts payments throughout the health care system. Intermediate entities that can manage financial risk and ensure quality of care are important in transitioning to value-based care within the Medicare program.

Response:

1. Prices are best for patients when they are known in advance of the receipt of services. This is absolutely disingenuous pretending to invoke market forces. It is difficult to find out cost ahead of services even when there is no urgency or emergency. No one needing urgent care is going to or can shop around for price. They just need care.
2. Intermediate entities that can manage financial risk and ensure quality of care are code words for insurance companies who can siphon Medicare payments into profits such as in MA and ACO REACH. The profit making incentive results in OVERPAYMENTS to MA insurance plans

(Pg 463) Reduce waste, fraud, and abuse, including through the use of artificial intelligence for their detection

Response: AI has been used in MA plans to review the required prior authorizations under MA and review claims and deny care – NOT to reduce waste and abuse. MedPAC found that 1 in 7 denials should have been covered under Medicare. Despite those denials of care the spending growth in Medicare Advantage continues. Since its inception MA has always cost more for each enrollee than would have been spent in TM. In 2009 MA spent 18% more per patient for the same services.

Remember the government pays Medicare Advantage insurers a set amount for each person who enrolls, with higher rates for sicker patients. And the insurers, have developed elaborate systems to make their patients appear as sick as possible, often without providing additional treatment, according to the lawsuits According to an investigation by the NYT who reviewed dozens of law suits and Inspector general Audits, 8 out of the 10 biggest MA insurers have submitted inflated claims. 4 of the biggest 5 (United health, Humana, Elevance and Kaiser) have faced federal lawsuits for doing so. 71 of 90 government audits uncovered net overpayments in MA plans with the accumulate effect of overpayments estimated at $600 billion between 2023-2031.

(Pg 464) Regulatory Reforms and Legislative Proposals for Medicare

(Pg 464) Medicare regulations restrict choice of coverage and care: The next Administration should reintroduce (and strengthen) the ACO REACH model ( Accountable Care Organization Realizing Equity, Access and Community Health)

(Pg 465) 1. Make Medicare Advantage the default enrollment option

Response: This would take away choice. This would give for profit insurers even easier access to Medicare enrollees and increase their access to profiteering from taxpayer dollars.

(Pg 464) MA program has been registering consistently high marks for superior performance in delivering high-quality care.

Response: This is absolutely false. There is no evidence that MA results in better health care outcomes.

(Pg 465) 2. Give beneficiaries direct control of how they spend Medicare dollars.

Response: this is absolutely false. 1. Under MA beneficiaries have restricted networks and thus restricted choice of where and by whom they want their care delivered to them. 2.Their doctors need to submit prior authorizations for care their patients want resulting in less direct control of how they spend Medicare dollars.

(Pg 465) Remove burdensome policies that micromanage MA plans.

Response: The current administration because of the findings of rampant fraudulent claims and denial of covered services in MA plans are attempting to decrease that fraud with increased watchdog policies. Removing these would result in increased fraudulent practices to maximize profit.

(Pg 465) 4. Replace the complex formula based payment model with a competitive bidding model and 5. Reconfigure the current risk adjustment model.

Response: The current risk adjustment model does not work well. It currently results in MA enrollees having less expensive health needs than their TM counterparts BUT MA insurers are paid as though all Medicare enrollees health needs are the same and require the same level of spending. This results in overpayment and thus siphoning taxpayer $ into MA insurer profits to the tune of $44-56 billion in 2022. This Project 2025 does not spell out what replacing and reconfiguring they propose. They give us no reason to conclude it would be fairer since they are lying about the “success” of MA.

(Pg 465) Legacy Medicare Reform

Base payments on the health status of the patient or intensity of the service rather than where the patient happens to receive that service.
Replace the bureaucrat-driven fee-for-service system with value- based payments to empower patients to find the care that best serves their needs.
Codify price transparency regulations.
Restructure 340B drug subsidies toward beneficiaries rather than hospitals.
Repeal harmful health policies enacted under the Obama and Biden Administrations such as the Medicare Shared Savings Program28 and Inflation Reduction Act.

(Pg 465) Medicare Part D Reform.

The “negotiation” program of the Inflation Reduction Act (IRA) should be repealed, and reforms in Part D that will have meaningful impact for seniors should be pursued. “Until the IRA is repealed, an Administration that is required to implement it must do so in a way that is prudent with its authority, minimizing the harmful effects of the law’s policies and avoiding even worse unintended consequences.”

Let’s see what Biden has up to…Hmmm. Lots of things that will piss off the equity-pirate crowd!

“Seniors are already seeing lower prescription drug prices with insulin capped at $35, free vaccines, and out-of-pocket costs for prescription drugs capped at $2,000 starting in 2025…President Biden’s Inflation Reduction Act will save millions of seniors money on some of the costliest prescription drugs on the market. Meanwhile, Big Pharma also executed over $135 billion in mergers and acquisitions in 2023 alone, while passing the cost to consumers. And eight of the 10 drugs selected for this year’s negotiation program raised their prices in 2024 – after all 10 drugs were already priced three to eight times higher in the United States than in other countries. President Biden knows how the Inflation Reduction Act is delivering for American families, and his Administration will continue the fight to lower health care costs for more Americans.”

Announcing that Manufacturers of 10 Drugs Remain at the Negotiating Table.
Let Medicare Negotiate Drug Prices for at least 50 Drugs Every Year.
Expand Cap on Out-of-Pocket Prescription Drug Costs.
Capping Medicare Cost-Sharing at $2 for Common Generic Drugs.
Access to Cell & Gene Therapies.
Expand the IRA’s Requirement that Drug Companies Pay Rebates When They Increase Prices Faster than Inflation
Keeping Health Insurance Premiums Low.
Closing the Medicaid Coverage Gap.
Keeping Kids Covered.
Closing Research Gaps in Women’s Health Research.
Making Home Care More Available.
Ensuring Access to Mental Health Care.
Cracking Down on Junk Insurance, Surprise Bills and Fees, and Confusing Health Care Pricing
Prevent More Surprise Medical Bills.
Crack Down on Junk Insurance.
Securing Medicare.
Protects Seniors’ Health and Dignity.

Strong Record on Expanding and Strengthening Health Care Nationwide

The President’s new actions are all in addition to an already impressive track record on fighting for the health care of Americans across the nation. Over the last three years, the President has:

Expanded health insurance through the ACA Marketplaces to an additional nine million Americans and helped over one million people in Missouri, North Carolina, Oklahoma, and South Dakota gain Medicaid coverage.
Extended postpartum Medicaid coverage to nearly 700,000 women across 44 states and the District of Columbia.
Kept children covered continuously in Medicaid and CHIP for a full year.
Made it easier for people to enroll in the ACA Marketplaces and Medicaid, including for older adults that are covered by both Medicaid and Medicare.
Made critical vaccines free for all Medicare beneficiaries as well as adults enrolled in Medicaid, with seniors on Medicare saving on average $70 in out-of-pockets for vaccines.
Lowered maximum out of pocket costs for Americans with employer and ACA coverage by an average of $400.
Capped out-of-pocket costs at $35 for a month’s supply of insulin for seniors and people with disabilities on Medicare.
Lowered coinsurance for seniors that took the 47 drugs covered by Medicare Part B that hiked prices faster than inflation in 2023, with some enrollees saving as much as $618 per dose.

MEDICAID

The video below is about a group that used to parachute into the Amazon to provide medical services. However, they’ve found that profound suffering from lack of medical care and basic dental, hearing and vision care exists right here in the US. What it says is that we need universal medical care.

(pg. 466) “The dramatic increase in Medicaid expenditures is due in large part to the ACA (Obamacare), which mandates that states must expand their Medicaid eligibility standards to include all individuals at or below 138 percent of the federal poverty level (FPL), and the public health emergency, which has prohibited states from performing basic eligibility reviews.“

(Hmmm. Maybe they should consider raising minimum wages, or creating childcare for working parents or something, versus complaining that there are just too many poor people who need medical aid.)

Time-out to understand one of the GOP’s favorite terms for funding!

What is a “BLOCK GRANT”?: Talkpoverty.org has a nice explainer here. Conservatives like this system.

It prioritizes local control, but lacks accountability – they are often used as slush funds that states use to fill budget gaps or other need, instead of their intended purpose.
It loses value over time. The dollar amounts are also CAPPED, with no flexibility to account for inflation or the addition of more people needing a particular service. The most well-known block grant is TANF – Temporary Assistance for Needy Families, which helps fewer and fewer families over the years due to this funding type.
Easy to eliminate later: Conservatives will often support block-granting federally guaranteed programs, thereby making them less accountable, and then support ELIMINATING block granted programs precisely because they are not accountable. “Rinse and repeat.”

(Pg. 466) Reform Medicaid financing, (mostly by restricting with block grants and caps which they believe will “incentivize states to save money and improve the quality of care.”
(Pg. 467) Direct dollars to beneficiaries more effectively and responsibly. Jargony statements with no explanation.
- End state financing loopholes. (What does this mean?)
- Reform payments to hospitals for uncompensated care. (What does this mean?)
- Replace the enhanced match rate with a fairer and more rational match rate. (What does this mean?)
- Restructure basic financing and put the program on a more fiscally predictable budget (which should include reform of Disproportionate Share Hospital payments to hospitals). (This appears to be a rant that states that didn’t expand Medicaid programs don’t get as much money. – This is the GOP’s own fault.)
(Pg. 467) Incentivize states to save money: (What does this mean?)
(Pg. 467) Improve Medicaid eligibility standards to protect those in need. “Improve” means to make it harder to get Medicaid.
- Hold states accountable for improper eligibility determinations. (Punitive)
- Require more robust eligibility determinations. (Make it harder to get care)
- Strengthen asset test determinations within Medicaid. (Make it harder to get care)
(Pg. 467) Conduct oversight and reform of managed care. (Reference explaining this not longer has functional link, so who knows WTF this means.)
(Pg. 467) “Incentivize personal responsibility. Personal responsibility and consumer choice for Medicaid recipients must go together as standard. Medicaid recipients, like the rest of Americans, should be given both the freedom to choose their health plans and the responsibility to contribute to their health care costs at a level that is appropriate to protect the taxpayer.” How about just getting them the care they need? We’re talking poverty-level folks here!
(Pg. 468) Add work requirements and match Medicaid benefits to beneficiary needs.
- Adopt work incentives for able-bodied individuals
- Add targeted time limits or lifetime caps on benefits to disincentivize permanent dependence. (Yes, this will be great for hospitals who will then increase their uncompensated care! But they are going to “reform” that, so who knows?)
(Pg. 468) Allow private health insurance. (Private equity firms need profits!) They want states the option of contributing to private insurance accounts that rewards healthy behaviors. along with catastrophic coverage combined with an account similar to a health savings account (HSA). WARNING! “…a HSA-eligible health plan was associated with a decline in (non-preventive) outpatient office visits for workers at all income levels, but the decline was over twice as large for workers and their dependents with incomes less than $50,000 as compared with those with incomes of at least $100,000.“
(Pg. 468) Increase flexible benefit redesign without waivers. These are the essentially “skinny” health plans. The author also seems really worried about middle-income to upper- income Medicaid recipients getting too much in services.
(Pg. 468) Eliminate current waiver and state plan processes. Basically this is to allow them to add work requirements and remove non-health care benefits and services related to climate change, which they don’t believe in.

AFFORDABLE CARE ACT AND PRIVATE HEALTH INSURANCE

What ACA (The Patient Protection and Affordable Care Act) under Obama did:

The law created state-run marketplaces – with websites akin to online shopping sites – where individuals can compare prices as they shop for coverage. Some of the more popular provisions included:

Children can stay on their parent’s healthcare plan until age 26
No one who is sick or has a medical condition can be denied insurance
Companies can no longer charge women more than men
Businesses with more than 50 full-time employees must offer health insurance

A reminder of what Trump did to sabotage the Affordable Care Act…

Reduced outreach and opportunities for enrollment in the ACA’s insurance exchanges.
Cut ACA subsidies to insurance companies offering coverage on the exchanges.
Construct off-ramps to cheaper, lower-quality insurance.
Promoted waivers that would decrease ACA enrollments and undermine its regulatory structure.
Discourage legal “aliens” from enrolling in Medicaid.
Tried to get the Supreme Court to invalidate ACA

…and what he wanted to do.

(https://www.bbc.com/news/world-us-canada-39810145)

Would have pushed 21 million people off ACA under the Graham-Cassisdy Health Care Bill
Promoted waivers to charge the elderly more.
Promoted removing the individual mandate and penalty.
Promoted ending the mandate for companies with 50 or more employees to offer insurance.
Promoted waivers that allow the end mandatory coverage of certain health conditions, such as vision and dental care for children, hospital care, and outpatient services.
Such waivers could allow insurers to set caps – a maximum amount – they will pay for an individual’s medical services – a practice that Obamacare had prohibited.
Promoted waivers that allow insurance companies to drop coverage for maternity care and contraceptives.
Would ban women from using government money to buy plans that covers abortion and ends non-abortion Medicaid reimbursement to Planned Parenthood, a non-profit group that provides abortion services in some of its clinics, for one year.
States could impose a work requirement for individuals on Medicaid, although the disabled and pregnant women would be exempted.
Promoted allowing states to opt-out of requirements that insurers charge the same premiums for healthy and sick customers
Starting in 2020 it would distribute money the federal government currently spends on Medicaid to states in the form of “block grants” that are capped based on a state’s population and whose growth is limited. 34 states would see reduced government support for Medicaid and tax subsidies for individual purchasing health insurance, dropping federal outlays on Medicare by $175bn from 2020 to 2026.
States that agreed to expand their Medicaid coverage under Obamacare would be hit the hardest, as their additional funding would be phased out. In 2027 all federal block-grant funding would have to be re-authorised by Congress or it would end.
Allows states to devise their own insurance subsidy plans. It expands the contribution limits on tax-free health savings accounts (HSAs) and allows individuals to use them for insurance premiums as well as out-of-pocket healthcare expenses and insurance co-payments.

This is all to distract us from what we need, which is Medicare-for-All. Now, back to our regularly scheduled program chugging through their dreck.

(Pg. 469) Remove barriers to direct primary care. “Direct primary care (DPC) is an innovative health care delivery model in which doctors contract directly with patients for their care on a subscription basis regardless of how or where the care is provided.…DPC’s fixed fee for care does not constitute insurance in the context of health savings accounts.” Nor does it cover specialists, testing or hospital charges in an emergency. They helpfully suggest you take out a high-deductible insurance policy to cover landing in the hospital.
Revisit the No Surprises Act on surprise medical billing. Ah, we knew they’d be sad about it.
“The No Surprises Act protected consumers against balance bills, but it also established a deeply flawed system for resolving payment disputes between insurers and providers.” Figure it out. Fix the wording that allows insurance companies to take advantage of providers, but don’t go back to sticking patients with the bills. Patients are not always able to “shop” for the best prices, especially in emergencies or health care deserts.
Facilitate the development of shared savings and reference pricing plan options. This is a game. If you don’t utilize medical care, they are not going to give you your money back.
Separate the subsidized ACA exchange market from the non-subsidized insurance market. Oh, we see… This is to allow the non-subsidized market to buy skinny plans, or as they say “relief from the costly ACA regulatory mandates.“
Strengthen hospital price transparency. “these efforts could deliver considerable savings for consumers.” Once again “Patients are not always able to “shop” for the best prices, especially in emergencies or health care deserts.”

(Pg. 470) Center for Consumer Information and Insurance Oversight (CCHO). “Market innovation” in insurance plans = “pauper” plans for consumers that don’t cover them when they need it. “Short-term, limited-duration insurance policies would be unlikely to include all the elements of PPACA-compliant plans, such as the preexisting condition exclusion prohibition, coverage of essential health benefits without annual or lifetime dollar limits, preventive care, maternity and prescription drug coverage, rating restrictions, and guaranteed renewability. People who need health care would likely face financial hardship under these plans.” The goal was affordable health care for all, not affordable private health plans no matter how worthless they are. We need to replace Congress and the administration with people who understand and care about the difference.“